Quality Account
2014/15
Contents
Foreword ............................................................................................ 1
Director’s statement .......................................................................... 4
Independent Auditor's Limited Assurance Report to the Directors
of East Cheshire NHS Trust on the Annual Quality Account .......... 5
Our year at a glance 2014 -2015 ........................................................ 9
Our performance against 2014-15 quality priorities ...................... 10
Specified indicators ......................................................................... 20
Core indicators 2014/15 ................................................................... 23
Our performance in 2014/15 ............................................................ 30
Commissioning for Quality and Innovation (CQUIN)* ................... 32
Examples of good practice and patient stories* ............................ 33
Our patient and staff feedback........................................................ 38
Service users – what is important to them? .................................. 40
Audit participation ........................................................................... 47
Audit examples of good practice .................................................... 66
Participation in clinical research .................................................... 73
Quality Priorities .............................................................................. 74
2015/16 .............................................................................................. 74
Quality Strategy ............................................................................... 75
Quality improvement ....................................................................... 77
Quality Improvement Model ............................................................ 78
Our quality priorities for 2015 - 2016 .............................................. 79
Statements of assurance ................................................................. 86
0
Foreword
East Cheshire NHS Trust is totally committed to providing the best care in the right place
and while we remain focused on improving quality, delivering safe, effective, personal care
with dignity and compassion and can demonstrate this in many ways, there is more to our
vision and aspiration.
To ensure we deliver what our patients tell us they want and to meet commissioner
expectations, we need to offer greater accessibility to a wider mix of health professionals
that go beyond support when people are ill. As a trust, we have invested more in integrated
care, community care and out-of-hospital care, expanding services and laying the
foundations for better ways of delivering care. It is also noted following our commissioners’
comments that the trust recognises the work carried out in respect of adult safeguarding. We
have continued to invest in new technologies which increasingly enable clinicians and care
workers, affording more time to care.
While this is entirely in keeping with our plans, we must raise our ambitions further. We must
work differently to best deploy our resources, our people and our passion for great services
and care. By doing so, we will reach more of the people we serve as part of an NHS that
does not recognise organisational boundaries, though does reward consistently good clinical
outcomes and patient experiences. This is at the heart of our own clinical strategy and
partnership work- Caring Together in the East of Cheshire, Connecting Care in South
Cheshire and Vale Royal, together with the impact of Healthier Together and healthcare
devolution in Manchester - a Greater Manchester commissioning initiative that we have
embraced alongside our Southern Sector Partnership trusts.
We were the focus of a Care Quality Commission (CQC) inspection this year, which rated
the quality of a range of our services across each of five domains. I was pleased and proud
that the trust was recognised as ‘good’ for care consistently across all areas assessed. The
CQC’s report also pointed out many areas of best practice, which should provide assurance
to those using our services. That said, overall, we have been rated as ‘requires
improvement’, recognising there are areas of inconsistency in our service which we need to
put right. Over the next few weeks and months, we will place focus here to ensure when
reassessed, we move this rating to ‘good’ as a minimum, aiming for the best of the CQC’s
four rating grades, ‘outstanding’.
Examples of recognised good practice include:
 our community dental service team and the oral hygiene education programme that
is helping to improve children’s oral health, in addition to responding positively to
those with special needs;
 Good multidisciplinary team and agency working supported by good communication
between teams, agencies and at handovers between staff which supports seamless
care; discharge planning which is responsive to patients’ wishes;
 Community Parkinson’s nurses offering an ‘in-reach’ service for ward-based patients,
sharing expertise;
 expansion of the home intravenous therapy service which supports early discharge;
anticipatory pain relief prescribing for patients receiving palliative care to ensure a
speedy response to their condition.
I was also pleased that during the year, those with cancer were assured they were receiving
some of the best care and support in England when the trust was again placed in the top five
service providers nationally, by patients, in a Macmillan Cancer Support league table
measuring patient experience.
1
These examples evidence the trust’s drive to deliver personalised care and services for
patients and you can see more examples throughout this report.
Patient stories are key to this learning organisation and while we receive many accolades,
we know there is always room for improvement. Our assurance framework underpins the
recent introductions of new legislation, regulations and fundamental standards which makes
clear individual and Board responsibility for a high standard of patient care. Central to these
are the support for those to speak out, a Duty of Candour and assurances of fit and proper
persons.
United by common values, the trust’s Quality Account summarises our journey and what we
have accomplished as we deliver our annual plan, moving us closer to our vision, delivering
the best care in the right place.
Whatever challenges we face during the year, it is evident that our people and teams
contribute significantly to every patient experience. I would like to place on record my thanks
and those of the trust for your tireless and unwavering commitment to our patients through
the delivery of good personal care.
Thank you.
Chairman
East Cheshire NHS Trust
2
Chief Executive’s statement
Every day our staff have the privilege and responsibility of providing care to hundreds of
people across all ages and ethnicity, with acute or long term chronic illnesses, in high-tech
areas or in people's own homes.
Wherever we provide care we are united in an ambition to ensure the highest levels of safety
and quality are delivered to those who need us.
This ambition is only delivered through our continued scrutiny of the service we provide and
ensuring we are continually looking at innovations within and outside of the NHS to ensure
we are continually developing and improving.
We must also be open to learn from our own experiences when we sometimes do not meet
the standards we set ourselves. Patient surveys, staff feedback, external reports and
complaints are all a rich source of information to assist us in our vision of providing the best
care in the right place.
I hope that by reading the document you can get an understanding of the breadth of services
our dedicated staff provide and a flavour of their commitment to the patients we serve.
Best wishes,
John Wilbraham
Chief Executive
3
Director’s statement
Why are we producing a Quality Account?
East Cheshire NHS Trust welcomes the opportunity to provide information on the quality of
our services to patients, staff and members of the public.
In this document, we will demonstrate how well we are performing, taking into account the
views of our patients, staff and members of the public, and comparing our performance with
other NHS trusts.
All NHS trusts are required to produce an annual Quality Account, which is also sometimes
known as a quality report. We will use this information to help make decisions about our
services and to identify areas for improvement.
Statement of directors’ responsibilities in respect of the Quality Account.
The directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the
National Health Service (Quality Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
• the Quality Account presents a balanced picture of the trust’s performance over the period
covered;• the performance information reported in the Quality Account is reliable and
accurate;
• there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
and is subject to appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account. By order of the board.
Lynn McGill
Chairman
East Cheshire NHS Trust
John Wilbraham
Chief Executive
East Cheshire NHS Trust
4
Independent Auditor's Limited Assurance Report to the
Directors of East Cheshire NHS Trust on the Annual Quality
Account
We are required to perform an independent assurance engagement in respect of East
Cheshire NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality
Account”) and certain performance indicators contained therein as part of our work. NHS
trusts are required by section 8 of the Health Act 2009 to publish a quality account which
must include prescribed information set out in The National Health Service (Quality
Account) Regulations 2010, the National Health Service (Quality Account) Amendment
Regulations 2011 and the National Health Service (Quality Account) Amendment
Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the
following indicators:
 Percentage of patients risk-assessed for venous thromboembolism (VTE) (pages 59
and 62); and
 Rate of clostridium difficile infections (pages 60 and 62).
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy
themselves that:
 the Quality Account presents a balanced picture of the Trust’s performance over the
period covered;
 the performance information reported in the Quality Account is reliable and accurate;
 there are proper internal controls over the collection and reporting of the measures
of performance included in the Quality Account, and these controls are subject to
review to confirm that they are working effectively in practice;
 the data underpinning the measures of performance reported in the Quality Account
is robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and
 the Quality Account has been prepared in accordance with Department of Health
guidance.
The Directors are required to confirm compliance with these requirements in a statement of
directors’ responsibilities within the Quality Account.
5
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that:
Account is not prepared in all material respects in line with the criteria set
out in the Regulations;
specified in the NHS Quality Accounts Auditor Guidance 2014-15 issued by DH in
March 2015 (“the Guidance”); and
assurance in the Quality Account are not reasonably stated in all material respects in
accordance with the Regulations and the six dimensions of data quality set out in the
Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of
the Regulations and to consider the implications for our report if we become aware of any
material omissions.
We read the other information contained in the Quality Account and consider whether it is
materially inconsistent with:
 Board minutes for the period April 2014 to June 2015;
 papers relating to quality reported to the Board over the period April 2014 to June
2015;
 feedback from Eastern Cheshire Clinical Commissioning Group dated May 2015;
 feedback from South Cheshire Clinical Commissioning Group and Vale Royal
Clinical Commissioning Group dated May 2015;
 feedback from Local Healthwatch dated May 2015;
 the Trust’s complaints report published under regulation 18 of the Local Authority,
 Social Services and NHS Complaints (England) Regulations 2009, dated May 2015;
 the latest national patient survey dated 2015;
 the latest national staff survey dated 2014;
 the Head of Internal Audit’s annual opinion over the trust’s control environment
dated March 2015;
 the annual governance statement dated 2 June 2015; and
 the Care Quality Commission’s Intelligent Monitoring Reports dated July 2014 and
December 2014;
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with these documents (collectively the
“documents”). Our responsibilities do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of East
Cheshire NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that
they have discharged their governance responsibilities by commissioning an independent
assurance report in connection with the indicators. To the fullest extent permissible by law,
we do not accept or assume responsibility to anyone other than the Board of Directors as a
body and East Cheshire NHS Trust for our work or this report save where terms are
expressly agreed and with our prior consent in writing.
6
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. Our
limited assurance procedures included:
 evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators;
 making enquiries of management;
 testing key management controls;
 analytical procedures;
 limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation;
 comparing the content of the Quality Account to the requirements of the
Regulations; and
 reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient appropriate
evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information.
The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in materially
different measurements and can impact comparability. The precision of different
measurement techniques may also vary. Furthermore, the nature and methods used to
determine such information, as well as the measurement criteria and the precision thereof,
may change over time. It is important to read the Quality Account in the context of the
criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the
Department of Health. This may result in the omission of information relevant to other
users, for example for the purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or
non-mandated indicators which have been determined locally by East Cheshire NHS Trust.
Basis for qualified conclusion
The indicator reporting "Percentage of patients risk-assessed for venous thromboembolism
(VTE)" did not meet the six dimensions of data quality in the following respect:
Validity – during our sample testing we identified two short stay admission patients who were
recorded in the data set as not requiring a VTE assessment. This clinical assessment was
not documented in the patient’s notes. Whilst the Trust was able to retrospectively
demonstrate that this was the appropriate decision for these two patients, we were unable to
verify that this was the case for the wider population of short stay admission patients
included in the data set.
7
Qualified conclusion
Based on the results of our procedures, with the exception of the matter reported in the basis
for qualified conclusion paragraph above, nothing has come to our attention that causes us
to believe that, for the year ending 31 March 2015:



the Quality Account is not prepared in all material respects in line with the criteria set
out in the Regulations;
the Quality Account is not consistent in all material respects with the sources
specified in the Guidance; and
the indicators in the Quality Account subject to limited assurance have not been
reasonably stated in all material respects in accordance with the Regulations and the
six dimensions of data quality set out in the Guidance.
Grant Thornton UK LLP
4 Hardman Square
Spinningfields
Manchester
M3 3EB
4 June 2015
8
Our year at a glance 2014 -2015
April 2014
(Q4 / yr. end)
Trust starts work on
major energy-saving
scheme.
Macclesfield Hospital
colleagues win major
dentistry award
August 2014
Health visitors
awarded UNICEF’s
Baby Friendly Award
VitalPAC electronic
patient monitoring
system introduced
December 2014
Trust begins
providing specialist
community stroke
rehabilitation
services in South
Cheshire and Vale
Royal after a
successful tender bid
May 2014
June 2014
Community dental
clinics given Mouth
Cancer Foundation
accreditation.
Open day recruits
new nurses to the
trust.
Department of
Health Nursing
Director Viv Bennett
visits trust health
visitors in Crewe
September 2014
Community health
visitor becomes one
of the first in the
country to join a
prestigious national
fellowship
programme
Jan 2015 (Q3 report)
Local MP David
Rutley praises the
work of trust staff
after visiting hospital
and community
teams
Oct 2014 (Q2 report)
Friends and family
test rolled out to
outpatients
Mouth cancer
screening events
across Cheshire
February 2015
The Royal Voluntary
Service receives
funding to place
additional volunteers
in Macclesfield
Hospital’s
Emergency
Department.
July 2014 (Q1 report)
Local patients,
carers and family
members vote for
‘Patient’s Choice’
Staff Award
November 2014
Annual Staff Awards
held - district nurse
team leader Laura
Reynolds receives
Chairman’s Choice
Award.
Estates department
wins prestigious
Building Better
Healthcare Journal
award.
March 2015
Regional changes to
stroke pathways
introduced to
improve outcomes
for local patients.
9
Our performance against 2014-15 quality priorities
East Cheshire Trust provides a wide range of acute and community-based health care
services for the local population of east Cheshire, south Cheshire and Vale Royal.
The priorities demonstrate our commitment to deliver safe, effective and personal care,
working in partnership to develop innovative and integrated ways of working.
Our priorities for 2014-2015 focused around:
• Patient experience - specifically the NHS Family and Friends Test, ‘always events’
and outpatients.
• Clinical effectiveness - dementia and proactive care for patients with long-term
conditions.
• Patient safety – reduction in pressure ulcers and the open and honest care project
Our achievements against all of these priorities can be seen in the following section.
10
Proactive care for patients with long-term conditions
Target
The trust worked with our colleagues in health and social care to develop and deliver care
coordination in a consistent way for patients with complex needs. This included:
• Developing with colleagues in primary and social care an integrated proactive
care plan for use across agencies
• Developing the role of the care coordinator with community staff
• Ensuring that patients identified as at `high risk’ of being readmitted are provided
with a pharmacy review and are supported on discharge
• Health colleagues having direct access to clinical advice
Achievements
•
•
•
•
•
Partnership working across primary care, social services and ambulatory care to
develop documentation used by primary and community care
Development of processes to ensure that appropriate trust staff are notified that a
patient who is at high risk of being readmitted has been admitted and discharge is
supported
All patients identified as at high risk by primary care colleagues and on a community
caseload have a proactive care plan and named coordinator
All admitted high-risk patients have a full review by the Pharmacy Team and are
contacted by pharmacy after discharge to ensure that the patient fully understands
their medication
Development of a directory with contact details of clinicians who will support clinical
colleagues with advice
What this means for patients
•
•
•
Patients are supported to remain in their home
All patients have the correct medication for their needs
GPs will be informed about the admission and discharge of patients
Further improvements 2015/16
•
•
Continue to roll out the project
Review the trust’s directory of services
11
Friends and Family Test
The NHS Friends and Family test is an important opportunity for patients to provide
feedback on the care and treatment they receive with the aim to improve services. This
year a staff survey based on this has been introduced in line with national requirements.
Target
•
•
•
•
to implement the staff FFT survey
to increase or maintain response rate in inpatient and emergency department
surveys
to reduce the number of negative response rates for the FFT survey
to implement the FFT survey in day case and outpatient areas by October 2014
Achievements
Staff FFT
The trust implemented the NHS Staff Friends and Family Test in line with national
requirements. We surveyed staff across the year and triangulated the results with other
survey results. Combined, we will use them to inform plans to improve staff satisfaction and
engagement.
Patient FFT - inpatient/emergency department/maternity
The Friends and Family Test was introduced as a way of gathering feedback from patients
about their experience of the NHS.
It asked one question:
• How likely are you to recommend our ward/department to your friends and family if
they needed similar care or treatment?
• A paper, text message or on line survey is completed, giving feedback.
Our results for 2014/15 can be seen within the national performance standards on page 31
of this report.
Maternity ranked first nationally
During the months of October, November and December 2014, our maternity services were
ranked first out of 138 trusts nationally by the Family and Friends Test according to how
likely mothers were to recommend us for care in labour.
Themes
The top three positive themes identified across the trust by the Family and Friends Test
were:
• friendly and caring staff
• excellent care received
• good food
The top three themes for improvement were:
• lack of televisions that work in the wards
• poor choice of food for people with special dietary requirements
• staff are always busy
For the patients this means
• Patients can tell us about what works well and what needs improvement
12
•
•
•
We can see if there are issues that are being identified on a regular basis so that these
can be acted upon
It is motivating for the staff to get the positive feedback
Feedback is displayed on posters at the entrance to each ward on a monthly basis, so
patients are able to see for themselves what has been said about their ward
Further improvements 2015/16
• Work continues to improve the response rates and increase the options patients can
respond to the survey
• Work continues to improve the number of positive responses by making sure we listen
and act on the feedback given
• FFT will be rolled out to all community services during the next year. FFT results can be
seen on page 58 of the Annual Report
13
‘Always events’
Target:
•
to ensure that specific actions in relation to discharge always happen when a
patient is discharged from a ward
Achievements:
• to improve the patient experience, five actions or 'always events' agreed with a plan to
assess how effective these were
• to improve compliance with post-discharge instructions, discharge lounge nurses now
contact patients assessed as being at high risk of being readmitted by telephone to
check that everything that was required on discharged had been undertaken and to
reduce the risk of readmission into hospital.
• patients have been surveyed during March 2015 to evaluate if this has helped both the
patient experience but also supported a reduction in patients being readmitted.
•
•
•
For the patient this means:
they will have all the required information on discharge to ensure they understand their
treatment plan.
any medication they need at home will be given to them before they leave the hospital
and that their GP has been informed.
they will have a point of contact following discharge if they need to seek further advice.
14
Outpatients
Target:
•
•
to improve the process for managing outpatient appointments
to improve communication and the overall experience of patients attending
outpatient clinics
Achievements:
• new process in place to review, monitor and escalate issues relating to outpatient
appointments.
• the outpatient team have supported additional outpatient activity for specialties to
reduce the waiting times for appointments
• there have been excellent results from the patient satisfaction questionnaire
conducted quarterly in outpatients. See the trust website for further details
• there has been a reduction in PALS contacts relating to issues in outpatient services.
What this means for patients:
• patients are seen by their appointment time at clinic, if there are delays that these are
clearly communicated.
Further improvements 2015/16:
• to increase the use of Friends and Family Test in improving the service based on
feedback from our patients
• to develop more robust processes for the cancellation and reduction of clinics
• to improve the timeliness of the start times for outpatient clinics and reduce long
waits in clinics for patients
• to further reduce the instances of PALS contacts and complaints.
15
Dementia care - innovative practice
Improving the hospital environment and quality of care for people living with dementia
Target:
• To ensure patients are appropriately assessed, investigated and referred on to the
appropriate service
• To improve the diagnosis and referral of patients living with dementia and/or
delirium by screening eligible patients in line with national requirements.
• Provide a sensitive care environment that enhances the patient journey from
hospital admission to discharge. This was supported by capital investment
awarded by the Department of Health and Kings Fund to upgrade a ward by using
innovative environmental design principles for people living with dementia
• Improve patient and carer experience
16
Achievements:
• Review of assessment documentation used in the hospital
• Implementation of an electronic data collection tool to support timely assessments when
first seen by the medical team
• Implementation of ‘forget me knot’ symbol to raise awareness and improve
communication between staff groups supporting continuity of care.
• Proactive partnership working with local commissioners to agree and monitor progress
• Access to e-learning dementia care modules for all staff and development of an
innovative bespoke dementia training programme for all healthcare disciplines
• Dignity Action Day (February 2015). The trust held an event to encourage engagement
by means of a ‘dignity tree’ displayed on which suggestions for improvement relating to
dignity were written on leaves.
• Monthly carer surveys used to support clinical teams to develop further ideas, themes or
trends in order to further improve care for people with dementia
• Introduction and increased uptake of use of the ‘This is Me’ patient passport – a specific
passport for dementia patients endorsed by the Alzheimer’s Society
• Networks established with partner and voluntary organisations
• Implementation of a ‘Breakfast Club’ on Ward 9.
•
•
•
•
•
•
•
•
•
For patients this means:
We have a ward where the environment meets the specific care requirements of patients
living with dementia promoting the maintenance of social and enjoyable pastimes.
We have staff who have undergone training to give them the skills and knowledge to
care for patients living with dementia, allowing individualised, compassionate care.
We support the family and carers of patients living with dementia.
Further improvements 2015/16:
Develop options to replicate a dementia-friendly environment to any service redesign
within the trust
Implement a full range of co-ordinated activities on Ward 9
Continue to build workforce capacity and competency through ongoing staff training
Strengthen support mechanisms to share best practice and develop a ‘buddy’ ward with
Cheshire and Wirral Partnership NHS Foundation Trust
Identify dementia care champions and proactively work with voluntary organisations,
local communities, schools and colleges to increase awareness and encourage
dementia friends.
Secure patient representatives to attend and contribute to the annual work plan via the
dementia operational steering group
Reduction in pressure ulcers
Target:
The trust aimed to improve the assessment and management of patients in both
community and hospital settings who are at risk of developing pressure ulcers in the
following ways:
• To reduce the total number of newly-acquired pressure ulcers on caseload/during
hospital stay by 25%
• To develop a training package to support staff in their management of pressure care
• Improve the recording of pressure area information and visual assessment by use of
digital cameras
• To undertake a planned staff training programme across community and hospital
teams.
•
Explore and contribute towards the development of a dementia strategy.
17
Achievements
• E-learning package developed.
• Wound management and pressure ulcer prevention protocols updated
• Development of the skin care bundle for pressure ulcer prevention
• Development of staff information booklet on ‘top tips’ for prevention and grading of
pressure ulcer.
• Roll-out of pressure ulcer training to hospital staff and targeted training for individual
areas.
• Training delivered to assistant practitioners in the community for pressure ulcer
prevention.
• Plans to update photographs of pressure ulcers on digital systems to allow them to be
reviewed by the nurse specialist wherever they are located for prompt expert advice.
What this means for patients
Staff will have the right skills to identify risk and prevent skin damage.
•
•
Patients will have skin assessments undertaken within six hours of admission to hospital
and appropriate care started.
Further improvements 2015/16
Planned roll out of skin bundle to all areas by July 2015.
For all wards and community teams to have access to digital imaging by April 2015.
E-learning training to be rolled out and all staff to have access to it by April 2015.
•
•
•
Open and Honest Care project
This is focused on improving the quality of care provided to our patients when they
are admitted to our hospital wards and units.
•
•
•
•
Target
our overall aim is to further reduce harm and demonstrate this by publishing a specific
set of patient outcomes and patient and staff experience information
review current reporting systems and processes relating to clinical incident reporting
establish robust data collection and measures
develop and implement quality assurance frameworks to support ‘Open and Honest’
care reports
18
Achievements
• corporate nursing lead identified to drive and support implementation of ‘Open and
Honest’ care project supported by a project group
• presentation to Trust Board and senior nursing colleagues to provide clarity and
increased awareness
• established a ‘buddy’ organization to support implementation
• clinical templates have been developed to support clinical staff in collation of data with
regards to pressure ulcers and injurious falls
• patient and staff experience questions aligned to the reporting template
• ‘Did You Know’ monthly ward information posters amended to include this information
•
For patients this means:
receiving care and treatment that is safe and effective, at the point of need
•
•
•
•
Further improvements 2015/16
establish monthly reports
establish a website link to enable the public to view ‘Open and Honest’ care reports
use the information in clinical areas to improve patient care
implement skin bundle across all inpatient ward areas
19
Specified indicators
Auditors test two indicators annually according to the nature of the trust’s activities. For
2014/15 these indicators are venous thromboembolism (VTE) and C. Difficile.
VTE
The trust ensures that a minimum of 95% of patients have a VTE risk assessment completed
on admission, and that 95% of incidences of hospital-acquired VTE have a root-cause
analysis. The results are collated through an electronic system directly linked with the patient
administration system (PAS) for recording the completion of VTE assessments. The target
has been consistently achieved since December 2014.
Incidences of VTE are investigated by the patient’s named consultant; reports are fed back
to the VTE group for approval, comment and recommendation and then presented at the
appropriate speciality Safety and Quality Standards Committee (SQS) and clinical audits
meetings for shared learning.
In addition for 2015/16 the trust is developing a protocol for the management of high-risk
patients. In addition specific work is being undertaken for patients attending Macclesfield
Hospital’s Endoscopy and Treatment Unit. We are also revisiting the VTE eLearning
package to update in line with national and local requirements.
C. Difficile
More information about C. Difficile can be found on page 28
Please see page 5 for the audit opinion.
20
Data quality
Relevance of data quality and action to improve data quality
The trust’s Data Quality Policy states that all staff have responsibility for ensuring the quality
of data meets required standards. The Secondary Uses Service Dashboard is continually
monitored, areas for improvement are identified and quality errors, such as invalid NHS
numbers, are rectified. Overall, data quality is reported monthly to the trust board. The trust’s
overall data quality scores are better than the national average.
Data quality
Under figures for April 2014 to December 2014, the Secondary Uses Service Data Quality
Dashboard was at 97.2%, against 96.1% nationally. Meanwhile, for a valid NHS number
being present in the data, the scores are above the national average. Admitted patient care
was at 99.5% against 99.1%, outpatients was showing 99.9% against 99.3%, and accident
and emergency was significantly above the national average of 95.1%, at 98.7%. For a valid
Healthcare Resource Group version 4 code, the scores are 100% for the trust against
national scores of admitted patient care at 98.5%, outpatients at 98.6% and accident and
emergency at 96.1%.
Clinical coding
Clinical coding translates the medical terminology written by clinicians to describe the
patients’ diagnosis and treatment into standard, recognised codes.
The accuracy of this coding is a fundamental indicator of the accuracy of the patient records.
There is a robust internal clinical coding audit and training programme which was developed
in 2011/12. The trust has a Connecting for Health (CFH)-accredited auditor and trainer in
post.
Coding is carried out using the full patient case note supplemented by electronic systems,
such as histopathology and radiology, which is considered best practice.
The trust has not been subject to a Capita PbR audit in 2014/15.
Information Governance Toolkit
As part of the Department of Health’s commitment to ensure the highest standards of
information governance, it has developed an Information Governance Assurance Framework
supported by the Information Governance (IG) Toolkit.
The IG Toolkit is a self-assessment and reporting tool that organisations must use to assess
local performance in line with Department of Health requirements.
The Connecting for Health guidance states that all NHS organisations need to demonstrate
compliance with all IG Toolkit requirements through achievement of at least Level 2
attainment, and should be achieving Level 2 against all the requirements by 31st March
2015. The trust submitted evidence in March 2015, confirming Level 2 compliance against all
the requirements. The trust’s overall score was 67% or ‘green’ according to the IGT grading
system.
There is a requirement for 95% of trust staff to be trained in information governance on an
annual basis. The trust scored 96.75% during 2014-15
Review of services
During 2014/15 the trust provided and/or sub-contracted 13 NHS services. The trust has
reviewed all the data available to it on the quality of care in 100% of these NHS services.
The income generated by the NHS services reviewed in 2014/15 represents 100% per cent
21
of the total income generated from the provision of NHS services by East Cheshire NHS
Trust for 2014/15.
The trust systematically and continuously reviews data related to the quality of its services.
The trust uses its integrated Quality, Safety and Performance Scorecard to demonstrate this.
Reports to the Trust Board, Governance Committee, Executive Management Board, Quality
and Safety Board and the Performance Management Framework all include data and
information relating to our quality of services. The trust has reviewed all the data available on
the quality of care in all of these NHS services.
Counter-fraud
The trust operates a counter-fraud policy within the corporate governance manual for the
organisation which can be found on the staff intranet
22
Core indicators 2014/15
All trusts are required to include their performance against nationally-selected quality
indicators. In addition, the national performance average is required to be included. East
Cheshire NHS Trust’s performance against the selected national quality indicators is
presented below.
Quality
Indicator
East Cheshire
NHS Trust (ECT)
Data
Comparison
ECT considers
Actions to
against
that this data is improve this
worst/best
as described
score and so
performing
for the
improve its
trust and
following
quality of
national
reasons:
services by:
average
1: Preventing people from dying prematurely. Summary Hospital-Level Mortality Indicator
(SHMI):
A: SHMI value
and banding
July 2013 - June
2014
0.9644
(band 2 – as
expected)
9 trusts higher
than expected
15 trusts lower
than expected
113 trusts as
expected
Lowest = 0.541
Highest = 1.198
Average = 0.995
The trust
performs
within the
expected
range for this
indicator.
This is in line
with the trust
TDA submission
The trust
holds a
monthly
mortality subcommittee. All
inpatient
deaths are
reported on
datix and
mortality
figures
scrutinised to
enable the
effective
review of
every
inpatient
death. The
trust has a
Mortality
group
to provide
oversight
of any
required
improvements
2: Enhancing quality of life for people with long-term conditions
B: Percentage of
patient deaths
with palliative
care coded at
either diagnosis
or speciality level
16.9%
National average
= 24.6%
23
Quality
Indicator
East Cheshire
NHS Trust (ECT)
Data
Comparison
ECT considers
Actions to
against
that this data is
improve this
worst/best
as described for score and
performing
the following
so improve
trust and
reasons:
its quality of
national
services by:
average
3. Helping people to recover from episodes of ill-health or following injury. Patient
reported outcome scores for:
i)
groin
hernia
EQ5D Index:
England:
Health gain is
surgery
95.5%
EQ5D Index
marginally better
91.4%
than the England
average
ii, )
***varicose vein
surgery
Iii) hip
replacement
surgery
iv, knee
replacement
surgery (
primary)
90.6%
90.2%
84.6
90.2%
***Results are
unable to show
health gain as
numbers are so
small and
therefore not
included
24
Quality
Indicator
Comparison
ECT considers
Actions to
against
that this data is
improve this
worst/best
as described for score and
performing
the following
so improve
trust and
reasons:
its quality of
national
services by:
average
3. Helping people to recover from episodes of ill-health or following injury. Emergency
readmissions to hospital within 28 days of discharge:
i)
0-15
10.77 (2011/12)
England: 10.01
The trust performs
years of 11.70 (2010/11)
(2011/12)
within the
age
10.92 (2009/10)
10.01 (2010/11)
expected
10.01 (2009/10)
range for this
(% of discharge) No further annual
CECPCT (prior
indicator.
data available
to CCG): 9.98
from provided
(2011/12)
source
11.92 (2010/11)
11.69 (2009/10)
ii)
16-74
10.01 (2011/12)
England: 10.14
Years
10.68 (2010/11)
(2011/12)
9.94 (2009/10)
10.09 (2010/11)
(% of discharge)
9.92 (2009/10)
No further annual
CECPCT (prior
data available
to CCG): 9.40
from provided
(2011/12)
source
10.79 (2010/11)
10.06 (2009/10)
iii)
75+
Years
East Cheshire
NHS Trust (ECT)
Data
13.85(2011/12)
14.90 (2010/11)
14.29 (2009/10)
(% of discharge)
No further annual
data available
from provided
source
England:
15.29 (2011/12)
15.35 (2010/11)
14.86 (2009/10)
CECPCT (prior
to CCG): 14.40
(2011/12)
15.74 (2010/11)
15.03 (2009/10)
25
Quality
Indicator
East Cheshire
NHS Trust (ECT)
Data
Comparison
ECT considers
against
that this data is
worst/best
as described
performing
for the
trust and
following
national
reasons:
average
4. Ensuring that people have a positive experience of care
Actions to
improve this
score and so
improve its
quality of
services by:
Responsiveness
to inpatients’
personal needs.
65.6 (2013/14)
62.8 (2012/13)
66.2 (2011/12)
67.3 (2010/11)
66.5 (2009/10)
We undertake
regular
feedback
across all
inpatient
areas to
ensure we
remain
responsive to
patient needs.
We theme
responses
from FFT
comments to
in order to
improve our
services.
(Standardised
%)
England:
68.7 (2013/14)
68.1 (2012/13)
67.4 (2011/12)
67.3 (2010/11)
66.7 (2009/10)
Worst – 54.4
(2013/14)
Best – 84.2
(2013/14)
4. Ensuring that people have a positive experience of care
Percentage of
staff who would
recommend the
provider to
friends or family
needing care.
60% (2014)
England:
66.0% (ALL
ORGANISATION
S - 2014)
67.0% (ALL
ACUTE TRUSTS
- 2014)
Worst = 38.0%
Best = 93.0%
The family
and friends
test FFT .for
all staff
continues to
be monitored
and new ways
of
encouraging
staff
responses
sourced for
community
services to
enable greater
engagement
and
participation.
26
Quality
Indicator
East Cheshire
NHS Trust (ECT)
Data
Comparison
against
worst/best
performing
trust and
national
average
ECT considers
that this data is
as described
for the
following
reasons:
Actions to
improve this
score and so
improve its
quality of
services by:
4. Ensuring that people have a positive experience of care
% of inpatients
2014 -2015
ENGLAND
Please see
and patients
A&E 86.1%
64.4%
page 9 for
discharged from Inpatient 93.2%
94.38%
more
Accident and
information on
Emergency who
FFT.
are likely or
extremely likely
to recommend
the trust.
5. Treating and caring for people in a safe environment and protecting them from
avoidable harm.
Percentage of
admitted patients
risk-assessed for
venous
thromboembolis
m.
Q1-Q3 2014/15
97.74%
(latest published
information from
Health & Social
Care Information
Centre)
For information:
the trust reports
97.47% for Q1Q4 2014/15
Q1-Q3 2014/15
Best: Blackpool
Teaching
Hospitals
(99.9%)
Worst: North
Cumbria
University
Hospitals
(87.7%)
England:
96.1%
The trust performs
to required
standard
Ongoing
education of
medical and
nursing staff,
including
development
of e-learning
package
RCA s for all
hospital
acquired VTE
reviewed at
monthly VTE
group
Daily
monitoring
within wards to
ensure
compliance
27
Quality
Indicator
East Cheshire
NHS Trust
(ECT) Data
Comparison
ECT considers
Actions to
against
that this data is
improve this
worst/best
as described for
score and so
performing
the following
improve its
trust and
reasons:
quality of
national
services by:
average
5. Treating and caring for people in a safe environment and protecting them from
avoidable harm.
Rate of C
Difficile.
April 2013 March
2014 12.8
CDifficile
infections per
100,000 bed
days among
patients aged
two years and
over.
For up-to-date
C Difficile data
for 2014/15
please
see the National
Performance
Standards at
page 31.
England:
April 2013 March 2014
14.7 CDifficile
infections per
100,000 bed
days among
patients aged
two years and
over.
Best:
Birmingham
Women's
Hospital (0.0)
Worst:
University
College London
Hospitals (37.1)
The trust performs
to required
standard
We undertake
post-infection
reviews to
identify any
lapses in care
relating to CDI
toxin positive
cases
attributable to
the hospital.
Antibiotic
prescribing
formed one of
the trusts
CQUINS for
2014/15. The
measurements
were fully
achieved.
A multidisciplinary
team review is
undertaken on
a monthly
basis to
ensure that
patients with C
Diff toxin and
glutamate
dehydrogenas
e (GDH)
receive
optimal care to
enhance the
recovery
process.
28
Quality
Indicator
East Cheshire
NHS Trust
(ECT) Data
Comparison
ECT considers
Actions to
against
that this data is
improve this
worst/best
as described for
score and so
performing
the following
improve its
trust and
reasons:
quality of
national
services by:
average
5. Treating and caring for people in a safe environment and protecting them from
avoidable harm.
A web-based
Rate of patient
Reported patient Overall for acute incident reporting
Ongoing
trusts nonsafety incidents
safety incidents
system is used to training and
specialist
and percentage
capture incidents
education of
resulting in
The rate of
and is available to trust staff on
severe harm or
patient safety
all staff via PCs.
incident
death.
incidents
reporting.
reported per
The patient harm
Improved
1,000 bed days
field is mandatory process of
on the incident
check and
The proportion of
reporting form.
challenge for
patient safety
serious
incidents
All clinical
incidents.
reported that
incidents are
resulted in
reviewed by the
Duty of
severe harm or
Risk Management candour
death.
Team.
captured on
incident
Oct 13 - Sept 14
Training and
reporting
7705 incidents.
communication
system to
takes place.
improve
64 incidents per
compliance.
1,000 bed days
There is
Monthly data
0.49% resulting in ownership for all
produced and
0.06 % resulting severe harm or
incidents as all
sent to service
in severe harm
death
team leaders and lines on
of death
managers are
complaints,
Worst
assigned
PALS, patient
5 incidents
incidents to
experience,
83% resulting in
resulting in
investigate.
incidents and
severe harm
severe harm or
claims.
death, 39
The trust has a
1 incident
incidents resulting high-level
Incident data
in severe harm, 0 executive lead
resulting in
used to inform
death.
resulting in death. group which
improvement
considers all
initiatives
Best
serious incidents. such as Sign
0% resulting in
up to Safety.
severe harm or
All patient safety
death.
incidents which
resulted in serious
5 incidents
harm or death are
resulting in
verified by the
severe harm, 4 in head of safety risk
death.
and resilience
prior to upload.
29
Our performance in 2014/15
Quality performance
The trust is measured on its performance against the Department of Health NHS
Performance Framework, which provides a dynamic assessment of the performance of NHS
providers that are not yet NHS foundation trusts. The assessments are across four key
domains of organisational function - finance, quality of service, operational standards and
targets, and quality and safety. Performance is assessed quarterly.
The trust’s performance against national targets can be seen below. Other areas of
performance are illustrated throughout this section of the Quality Account and further
performance statistics can be found on the trust website at www.eastcheshire.nhs.uk
National context
Despite extensive planning and cooperation between all types of NHS organisations, the
health service faced considerable and widely-reported challenges on a national level over
winter 2014-15. This was largely due to emergency admissions and the number of patients
requiring admission to hospital – especially frail older people with complex health and social
care needs. As a result, most NHS trusts struggled to meet national targets, particularly the
four-hour emergency department standard, in the final two quarters of the year.
Trust access targets
C Difficile
The trust was set a maximum number of 14 cases in 2014/15, however the trust had 17
confirmed cases. Trust investigations indicated that in most cases, these instances were
unavoidable, however increased training to support clinical staff in the management of C
Difficile infections was carried out.
All individual C Difficile cases are reviewed to understand if there was anything that could
have prevented the infection and any learning is shared with clinical teams.
Delayed transfers of care
These are patients who no longer need to be cared for within an acute hospital bed as they
are medically fit for the next stage of their care. The trust has seen a significant increase in
the number of patients who are classed as being delayed. This is due to a variety of reasons
but the impact is a reduction in patient flow through the hospital, which impacts on our ability
to achieve the standards for both the Emergency Department and elective patients being
seen in 18 weeks.
Emergency access
The trust achieved the four-hour standard within the Emergency Department for the
first two quarters of the year but, like most other trusts, not the final two quarters due to
widely-reported winter pressures. Despite these challenges, staff across the trust both in
community and hospital settings worked extremely hard to ensure the needs of patients
were always met and high standards of care and safety were maintained.
18-week referral to treatment time
Many NHS organisations in England have been under increased pressure during 2014/15
due to the volume and complexity of emergency admissions. This impacted on planned
activity, with an increased number of patients having surgical procedures postponed. Some
patients have therefore waited longer than 18 weeks from GP referral to treatment. The trust
has an agreed plan to reduce the backlog by June 2015.
30
National performance standards – East Cheshire NHS Trust Results
The trust is working with commissioners and partners to strengthen local reporting of quality
outcomes, particularly in relation to community services.
2014/15
2014/15
2013/14
Target
Performance
Performance
>=90%
85.1%
89.6%
>=95%
96.8%
96.5%
18 week Referral to Treatment - Incomplete
>=92%
92.9%
93.6%
Diagnostic test waiting time within 6 weeks
>=99%
99.5%
99.2%
95%
93.16%
95.5%
>=93%
98.7%
97.8%
>=93%
95.3%
95.7%
31 day wait from cancer diagnosis to treatment
62 day maximum wait from urgent referral to
treatment of all cancers
62 days maximum from screening referral to
treatment
>=96%
99.00%
99.5%
>=85%
86.5%
88.8%
>=90%
98.4%
95.2%
Delayed Transfers of Care
<3.5%
9.2
5.2%
Mixed Sex Accommodation
0
0.58
0.06
>=95%
97.47
95.0%
0
1
1
14
17
15
Inpatient Wards
93.2%
92.0%
ED
86.1%
86.9%
Maternity (Overall)
94.5%
91.7%
18 week Referral to Treatment - Admitted
Patients
18 week Referral to Treatment - Non-Admitted
Patients
ED: Maximum waiting time of 4 hours
2 Weeks maximum wait from urgent referral for
suspected cancer
2 Weeks maximum wait from referral for breast
symptoms
VTE Prevention
Hospital MRSA
Hospital CDiff (Avoidable and Unavoidable
Combined)
Friends and Family Test (Positive Response Rate)
31
Commissioning for Quality and Innovation (CQUIN)*
Community Achieved
Community
Achieved
No
NHS Safety Thermometer
Yes
Long-term conditions / Proactive care
No
Pressure Ulcers
Yes
Family and Friends test ( Staff)
Acute Achieved
Acute
Family and Friends Test
NHS Safety Thermometer
Dementia
Reduction in emergency admissions – development of additional Ambulatory
Care Pathways
Long-term conditions / Proactive care
Achieved
Partially
No
Yes
Yes
Yes
Aseptic Non Touch Technique ( ANTT) training
Yes
Antibiotic Prescribing
Yes
Management of the acutely ill patient
Yes
Pressure Ulcers
No
Advancing quality
Partially
Always Events
Yes
Homecare medication
Yes
Healthcare Inequalities – Breast Screening
Yes
Specialist commissioner – Always events, patient discharge
Yes
Public health – Health inequalities – Breast Screening
Yes
Dental Commissioners – Early implementation to day case and outpatients
Yes
*The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare
providers' income to the achievement of local quality improvement goals.
32
Examples of good practice and patient stories*
Surgical Specialties
Quality Account Hip Fracture Pathway
Hip and Knee Rapid Enhanced Recovery Programme
The Rapid Recovery Joint Replacement Programme (RRP) was started on the 28th January
2013, with the primary aim to improve the quality of care for patients undergoing total hip
and knee replacement. The project involves multidisciplinary team working in collaboration to
support staff in the clinical area to follow the RRP. More than 400 patients have gone
through this joint replacement programme, resulting in a reduced average length of stay by
two days for both hips and knees. The primary aim is to improve the quality of patient care
by cultivating a shared responsibility with patients for their pre and post-operative care
through education and motivation. The gain for patients is that they will have less invasive
techniques such as catheters and drains, be mobilised sooner and spend less time in
hospital. The programme is rigorously audited.
Results (from 438 patients)
• More than half of all hip and knee replacement patients go home by postoperative
• There has been a slight reduction in pain score in both hip and knee patients
despite 50% reduction in strong opioid analgesia
• There has been a reduction in nausea and vomiting and slight increase in post-op
hypotension, which mostly appears to correct itself without any intervention.
• We have saved approximately £3,800 in analgesic drug costs since introducing
the programme.
• There has been a significant reduction in catheterisation - 96% of patients did not
require a urinary catheter and saved £6,699 in catheter consumable costs.
• Good patient satisfaction from telephone audit - the majority of patients
discharged on or before three days reported their length of stay as ‘just right’.
• Post-discharge pain appears to have been controlled effectively. The majority
reported that their pain was either ‘well controlled’ or ‘manageable’ while only a
minority of patients reported moderate to severe pain at night.
Hip Fracture Enhanced Recovery
The trust’s Enhanced Recovery Hip Fracture Pathway is a patient-focused, multiprofessional programme designed to reduce the morbidity and mortality in patients who have
sustained a fractured neck or femur.
The primary focus is to ensure that the health status of this vulnerable group of patients is
optimised and maintained from admission to discharge. The pathway ensures that patients’
abnormal health conditions are proactively managed and are given highly-calorific drinks to
maximise their nutritional status to promote post-operative healing. Opioid free spinal
anaesthetics are now standard to reduce the often high mortality risk of this group of
patients.
A multi-modal analgesic regime has been designed to provide effective pain control to
enable earlier mobilisation, while minimising the risk of analgesic side-effects.
The pathway involves two main documents; the Fracture Neck of Femur Clerking Proforma
and the Multidisciplinary Care Pathway. Both documents are interlinked and correspond with
the patient journey. The documents provide a framework to guide healthcare professionals
to deliver evidence-based, consistently high-quality care to all patients at all times.
This involves cohesive multidisciplinary team working and a shared responsibility with the
patient and carers to reduce the risks of hospital-acquired infections, postoperative
33
complications and cognitive impairment. The overall outcome is to improve the quality of
patient care by reducing delays to surgery, facilitate a speedier return to patients’ prefracture baseline and hopefully ensure an earlier discharge home.
Medical Specialties
Development of CPAP service
The Medical Specialities service line recently commenced a Continuous Positive Airways
Pressure (CPAP) service. This is a process that supports patients with obstructive sleep
apnoea syndrome (OSAS).
Undiagnosed and untreated OSAS can pose a serious health burden. It has been linked to
poor quality of life, increased risk of road traffic accidents (up to five fold), and increased risk
of uncontrolled diabetes and hypertension. There is emerging evidence linking it to adverse
outcomes in patients at risk of ischaemic heart disease (IHD) and stroke.
CPAP treatment consists of a positive pressure machine, mask (nasal or full face) and
tubing. Mild positive pressure is delivered to keep the upper airway open during sleep.
Across the country, the incidence of OSA and the associated syndrome (OSAS) has been
exponentially increasing. GPs and hospital doctors are becomingly increasingly aware of the
importance of diagnosis of OSA and are more alert to the symptoms and signs of the
disease. As a result, referrals to sleep clinics (run primarily by respiratory physicians) have
been steadily increasing. As an example, the trust received an increase of 20% in referrals
to this service in 2014 from 2013.
A bi-weekly new patient nurse-led clinic commenced in December 2014 in conjunction with
the consultant in respiratory medicine. The clinic is held in the main outpatient department at
Macclesfield Hospital and patients are remotely monitored unless the team feel it necessary
for patients to come into hospital for their follow-up. The new service has had very positive
feedback from these sessions and work continues to develop it further.
Clinical Support Services patient story
Cancer services
Last year, a lady attended Macclesfield Hospital’s Macmillan Cancer Resource Centre with
her partner, who had just being diagnosed with advanced bowel cancer. The treatment plan
was to offer palliative chemotherapy to the lady’s partner but his overall prognosis was poor.
The patient’s partner was understandably distressed following such a dramatic and
frightening outcome to what they believed would be a ‘straightforward’ oncology
appointment.
The patient started his chemotherapy and he remained positive and physically well for some
time but his partner was extremely anxious throughout, putting on a brave face to the outside
world, while sharing her fears for the future with members of the team.
The financial advisor service within the trust (based with Age UK, who would normally only
see those aged over 50 years) met with the couple, in the early stages of the patient’s
treatment as they had financial concerns. The advisor was able to clarify the application
process of different benefits and signpost to agencies to help with future planning. This was
found to be extremely helpful and reassuring.
34
As the patient’s condition sadly deteriorated, the concept of dedicated person-centred
counselling support for his partner was introduced (the patient himself declined this offer)
which she engaged with at the Cancer Resource Centre with one of the volunteer
counsellors. This continued until the patient’s sad death, several months after the initial
meeting with the couple, and a further ten weekly sessions of counselling were offered.
Following this, a referral to the dedicated bereavement support team would be made if it was
felt that on-going support was needed. This voluntary organisation is an important link to
bereaved clients.
During this time the couple decided to get married. The team were made fully aware of the
arrangements and enjoyed sharing their special day through photos and reminiscing. The
volunteer complementary therapist who had been helping the patient’s partner offered free
additional relaxation therapies in the lead-up to the wedding to help the lady’s heightened
anxiety.
As a team working in the Macmillan Cancer Resource Centre, we felt privileged to have
been able to offer a complete holistic approach to the care of both people in this story for
almost a year. They became well known to our chemotherapy team and Macmillan
pharmacists who worked to ensure the most positive experience possible for the patient and
our non-clinical support team ensured his partner especially was kept ‘safe’ throughout this
sad time.
NIMO pharmacy success story January 2015
The NIMO (Neighbourhood Integrated Medicines Optimisation) service is a new innovative
pharmacy service to support patients with complex medication needs, in their own homes.
The team comprises of two clinical pharmacists and one technician. An example of a patient
story is as follows:
A house-bound patient was referred into the NIMO service by a Knutsford GP.
A comprehensive medication review was conducted by NIMO pharmacist in the patient’s
own home. The current medication was assessed against her medical conditions, relevant
diagnostics results and any non-prescribed medication she was taking. A physical
assessment of her falls and fracture risk and blood pressure was also carried out.
The review of the patient’s own medications revealed some medication was out-of-date,
including oral diabetic medication and insulin, which had been stored inappropriately.
Blood sugar checks were regularly taken and recorded by patient but on review these
showed as abnormal. In discussion with the patient the pharmacist realised that the patient
had no understanding of what medication she should be taking at what time.
There also appeared to be a stockpiling issue – for example 16 boxes of eye drops were
found unopened in her cupboard.
Outcome
The patient’s GP was informed of her non-compliance, poor management of diabetes and
stockpiling of some medicines. The NIMO pharmacists discussed the issue with the patient’s
community pharmacist and an arrangement was made for them to provide blister packs for
her medication and to deliver/ collect old blister packs each week in order to monitor
compliance.
35
The NIMO pharmacist also referred the
patient to a community matron to support on
the management of her long-term
conditions.
Without this NIMO visit the issues may have
gone unnoticed, the patient’s own
medications would not have been reviewed
and the patient’s uncontrolled diabetes
could easily have resulted in a lengthy
hospital stay as well resulted in diabetic
complications.
“The staff in Macclesfield A&E are
amazing. I was in just before
Christmas with a fractured back
and yes I had to wait for three
hours, but so what? I was offered
pain relief while I waited and I
knew as soon as they could they
would see me. If waiting means
that the nurses and doctors can
work on someone fighting for their
life, or the more vulnerable,
personally I'd wait all day!!”
The NIMO service working closely with GPs
and other health care professionals as well
as access to hospital systems allowed for
efficient and seamless healthcare.
Allied Health Services – patient story
Community Stroke Rehabilitation Team
The following patient story illustrates the patient pathway and the benefits of receiving
interventions from the Specialist Community Stroke Rehabilitation Team (SCSRT). This
service is provided by East Cheshire NHS Trust to Mid Cheshire Hospitals NHS Foundation
Trust.
The patient was admitted to the Acute Stroke and Rehabilitation unit at Leighton Hospital,
Crewe. She had a diagnosis of a stroke which resulted in left-sided weakness. She also had
memory problems.
Prior to her stroke, the patient had been fully independent for indoor/outdoor mobility and all
aspects of domestic and personal care and lived at home with her husband.
After the initial therapy assessments, the patient had a predicted length of stay of one to two
weeks. She was given a predictive discharge date of February 3rd 2015.
The therapy team on the ward identified the patient suitable for SCSRT. The therapy teams
liaised closely and it was agreed that the patient would be discharged into the team as soon
as possible on Community Pathway 1. This meant that the patient would receive highlyspecialised input at a high intensity in order to maximise her potential functional recovery
and minimise any risk in her ability to achieve agreed goals.
Carer training took place on the ward and agreed times to visit at home.
The patient was discharged home on January 22nd 2015 (11 days prior to her predicted
discharge date) and was first seen in her home on the 23rd of January.
The patient was assessed in her home environment. Advice and home exercise regimes
were given. Goals were discussed and set with the patient and her husband.
A timetable of therapy visits were discussed and agreed with the patient and her husband
and she immediately received a seven-day therapy service. The patient reported that she felt
she was improving on a daily basis, becoming stronger and more co-ordinated. She also
reported that her dependence on her husband for assistance with tasks was decreasing.
36
The patient was discharged from the SCSRT three days earlier than her initial predicted
discharge on the 31st of January.
The patient was fully independent in her mobility both indoors and outdoors and she was
safe ascending and descending the stairs independently. The patient was also independent
in her self-care, being able to shower and dress independently, and she could also cook a
meal safely, do the laundry and vacuum her home.
What this meant for the patient
• Discharge from an acute hospital environment 11 days prior to the predicted
discharge date.
• Immediate access to specialist community service in stroke care. (Can also access
speech and language therapy, psychology, specialist nursing and dietetics as
required).
• Access to a seven-day therapy service.
• Opportunity to set shared meaningful goals.
• Opportunity to practice functional activities in her own home, making them more
meaningful and available, incorporating them into daily routine rather than isolated in
therapy treatment sessions.
• Consequently discharge from the stroke service as a whole was three days prior to
the predicted discharge date initially set in the hospital environment.
Integrated Care - patient story
The patient was a 68-year-old lady who lived alone but had family living nearby. She was
known to the district nursing team for many years, originally for treatment and care of
ulcerated legs.
The patient was bariatric but her weight was not established as she was unable to be
weighed. Her weight was estimated at approximately 40-50 stone.
She had been bedbound for the previous two years and was only able to lie on her left side
and required carers to help her move. She initially had three carers to help but this was
increased to four carers as moving the patient became more difficult. The district nurses
visited each morning with carers to assess and dress ulcerated areas on her abdomen and
legs and to check pressure areas.
As the patient’s condition deteriorated, the visit would take up to an hour. The patient was
nursed on a special mattress but due to her condition she was unable to sit up or get out of
bed.
The multi-disciplinary team met to discuss the best way to manage the patient’s care as her
condition deteriorated and her preferred end-of-life care planned. This was agreed in
conjunction with herself, her family and GP.
The patient wished to remain in her own home and practical issues such as meeting with the
funeral director to discuss after-death arrangements were facilitated. The patient
deteriorated quickly in last two days of her life but due to the preparation it meant that the
difficult and complex arrangements following her death had already been agreed with the
family and her end-of-life wishes were met.
*Patients have consented to the use of their stories although names have not been used in order to protect their
identity
37
Our patient and staff feedback
The trust carries out surveys annually in order to ensure we are meeting our patients’
expectations and where we are not, to formulate action plans for improvement. All local
surveys are published on our trust website and can be found at:
http://www.eastcheshire.nhs.uk/Get-Involved/Patient-Surveys.htm. All national surveys
can be found on the CQC website http://www.cqc.org.uk/content/surveys.
The detail of the National Cancer Survey published by Quality Health can be found at
https://www.quality-health.co.uk/resources/surveys/national-cancer-experience-survey/2014national-cancer-patient-experience-survey
A summary of our annual surveys and the impact on patient care can be seen below.
Local feedback
East Cheshire NHS Trust is fully committed to improving the experience of all its patients.
Listening, and more importantly, acting on patient feedback helps us to develop our services
to ensure the best possible patient experience.
To this end a full programme of patient feedback work has been carried out across all areas
of the trust covering a wide range of different subjects. The table below details the areas
covered. Summaries of all our patient feedback exercises can be viewed on our website at
http://www.eastcheshire.nhs.uk/Get-Involved/Patient-Surveys.htm
Example of local survey – mole mapping
Following the introduction of a new ‘mole mapping’ clinic at the trust, a feedback exercise
was undertaken to evaluate the level of patient satisfaction with the new service. Mole
mapping is a procedure where a special digital camera is used to record the positions and
appearances of moles on a person's body so that regular checks will detect any changes
that might lead to skin cancer.
A total of 118 self-completion questionnaires were posted out over summer 2014. 64
completed questionnaires were returned giving a response rate of 54%. Some of the
feedback included:
•
•
•
•
92% of patients referred to the mole mapping service felt the length of time they had to
wait for an appointment was acceptable.
89% of patients did not feel that they were lacking any information prior to attending their
appointment.
95% of patients said that the mole mapping procedure was ‘definitely’ explained to them
in a way that was clear and easy to understand and 98% of patients ‘definitely’ felt able
to ask any question or raise any concerns.
97% of patients said that staff ‘definitely’ did all they could to make them feel at ease
during the procedure and 97% also said that they ‘definitely’ had enough privacy during
the procedure.
What this means for the patient
Following the survey, an action plan has been developed to ensure that no patient should
wait longer than 18 weeks to be seen from initial referral to the service and improvements
have been made to the appointment system to reduce the number of cancellations and
moved appointments. Work is also underway to ensure that patients are clear what changes
in their moles they should be looking for as this will provide further reassurance to patients.
38
Areas covered by our patient feedback programme 2014-2015 include:
Bowel function
Surgical Specialities
Colorectal cancer
Stoma support
Breast screening
Clinical Support and
Diagnostics
Endoscopy and treatment unit
Comfort audit
Children's community nursing
Colposcopy
Women and Children
Gynaecology oncology
Sexual health
Children's Ward
Urgent Care
National CQC survey carried out within this service line
Dermatology
Chronic pain
Mole mapping
Medical Specialities
Specialist diabetes nursing
Melanoma follow up
Inpatient stroke services
Audiology
Community stroke rehabilitation
Diabetic retinopathy screening
Allied Health
Therapies at MCHFT
Community physiotherapy / occupational therapy
Wheelchair service
Paediatric therapies
HITS
Integrated Care
Intermediate bed based care
39
Service users – what is important to them?
It is essential to the trust to gather the views of our service users in as many different ways
as possible.
Health Matters
Each month we present a free public lecture – Health Matters - giving members of the public
the opportunity to learn more about health issues that affect or interest them.
People attending the talks can also meet local consultants and healthcare staff and put
questions directly to them. The Health Matters series covers a range of popular clinical areas
and has been an outstanding success in delivering key messages directly from senior trust
staff to the community they serve.
Health Matters lectures over the year covered topics including:
• Rapid recovery from joint replacement
• Organ donation
• Dementia
• Behind the headlines of A&E care
• Stroke
For a full programme, see the trust website at www.eastcheshire.nhs.uk
“Lots of useful information on dental
hygiene and I thought I knew it already”
“Very exciting and valuable
possibilities for healthcare in the future
- huge potential for the future”
40
Your views matter
During a number of Health Matters talks we also sought the views of our service users to
assist us in the action plans for delivery of our Quality Account. A series of questions and
their responses can be seen below.
What do you consider to be the five main contributors to improved quality care?
(outside of the clinical requirements?)
Staff introducing themselves when they meet you
29
Patient information (written)
21
Patient information (digital)
8
Improved staff communication with patients ( Priority 3 - Listening and
responding - Care that provides a positive experience for patients, carers and
families)
Bedside entertainment
51
A nice environment to wait in for your clinic appointment
8
Cleanliness - (Priority 1: Harm-free care)
55
Knowing which nurse and doctor is responsible for your care ( Priority 2 Improving outcomes - care that is clinically effective)
55
Food
16
Effective pharmacy
6
Timely discharge
11
Privacy
12
2
Assistance with feeding
6
On site shop
1
Car parking
11
Visiting hours
2
Appointment reminders
4
Discharge information and follow up care – knowing where to go ( Priority 4 Integrated care - Care that is co-ordinated and based around individual needs)
Exercise and diet advice
47
5
Other ( please detail)
Comments:
• Staff with time to treat you with courtesy and compassion.
• More help for people with disabilities – eg Alzheimer’s, hearing, blind
• Cleanliness – quality care would demand it as a basic – to improve quality care other
aspects must be considered
• Improve communications - explain care plans, pros and cons and alternative
treatments
• Reassurance every half hour for patients waiting for results in the emergency
department.
41
PLACE (Patient-Led Assessments of Care Environment) 2014
The trust undertakes the national PLACE report each year which seeks to provide
information for the trust from patients on its delivery of the care environment.
The trust carried out the assessment of Macclesfield in March and Congleton in June. The
assessment was undertaken by nine staff from Infection Prevention and Control, Nursing,
Facilities and contractors and a large team of eight volunteer patient assessors.
The aim of PLACE assessments provides a snapshot of our organisation and how it is
performing against a range of non-clinical activities which impact on the patient experience
covering areas of:
•
•
•
•
cleanliness;
the condition; appearance; maintenance of the buildings and grounds of the
healthcare premises;
the extent to which the environment supports the delivery of care with privacy and
dignity and;
the quality and availability of food and hydration.
The criteria included in PLACE assessments are not standards, but they do represent both
those aspects of care and good practice as identified by professional organisations whose
members are responsible for the delivery of these services, including but not limited
to the Healthcare Estates Facilities Managers Association, the Association of Healthcare
Cleaning Professionals and the Hospital Caterers Association.
Cleanliness
Food and
Hydration
Privacy, Dignity
and Wellbeing
Condition
Appearance and
Maintenance
Average Score
National
Average 2013/14
99.91%
94.38%
94.24%
97.86
96.60%
N/A
98.64%
93.84%
97.62%
95.65%
96.44%
N/A
N/A
91.43%
97.30%
89.10%
87.40%
91.90%
North
West
National Scores
Cleanliness
East Cheshire
NHS Trust
Congleton War
memorial Hospital
East Cheshire
NHS Trust
Macclesfield
Hospital
Site Name
Organisational
Name
42
The cleanliness scores on both sites have risen very slightly compared to last year which
has been mainly due to working with the contractors more closely when monitoring the
service.
Food and hydration
The food and hydration results increased at Macclesfield site this year as we have been
working with our catering partner to improve the quality of the service, listening to the
patients and within the contract parameters to improve the patient experience and
monitoring the wards regularly. At Congleton Hospital the results were slightly down on last
year. The choice of menu on the day was cooked and presented well but the choices offered
were not liked by the panel and therefore marked down. This was rectified immediately after
the audit with the contractor on site.
Privacy and dignity
Privacy and dignity results were lower than the previous year. The questions included:
“When patients are given distressing news can the patient leave the department via another
entrance? Or do they have to leave by walking back through the department?”
Unfortunately, we have several areas that do not have this facility.
Condition, appearance and maintenance
Condition, appearance and maintenance provided the trust with a much-improved score due
the continuing maintenance and decoration improvements at both hospitals. There has been
an increase in signage across the trust and vast improvements to the car parking and road
surfaces boosted the scoring.

On the previous page is a table showing the PLACE results trust hospitals have
received, together with average scores for other hospitals in the region. All three trust
sites scored above regional averages by all measurements.
“I was quite scared when I came in and
several of the nurses helped me through it.
Everyone was kind and considerate - surgeon
was excellent. Thank you.”
“My wife, who has Alzheimer’s, was admitted
for observation after a fall - during her seven
days before discharge she was cared for with
understanding and attention by all the staff
who made her stay as comfortable as
possible.”
43
Quarterly audits – inpatients
The trust is committed to regular patient feedback demonstrated by quarterly audits across
all inpatient areas looking at key areas including the patient’s experience of the ward
environment, views on care and treatment, preparations for discharge and overall views on
the level of service and care received.
During 2014/15:
• 81% of patients rated the cleanliness of
the ward as ‘very clean’
• 70% of patients stated that they were
‘definitely’ involved in decisions about their
care and treatment
• 94% ‘always’ had enough privacy when
being examined or treated
• 96% of patients said they were ‘always’
treated with dignity and respect
• 92% of patients said they were ‘definitely’
treated with care and compassion
• 71% of patients rated the overall level of
care as ‘excellent’ and 27% rated it as
‘good’
“I was very impressed with the attitude of
the staff and the speed with which they
dealt with me. I arrived at A&E at 8:50am
and left to go home at 10:10. Amazing!”
“I was really impressed with my care from
start to finish. Everyone was really
sensitive and helpful.”
For the patient this means that we are maintaining a high standard of care on our wards
ensuring that patients are always involved in decisions about their care and are treated with
dignity and respect, care and compassion at all times.
Quarterly audits – outpatients
In addition to the quarterly inpatient survey, we also conduct a quarterly audit across
outpatient areas. This audit covers the patients’ experience of the department, the care and
treatment received, leaving the department and overall views on care and service received.
During 2014/15:
• 87% of patients rated the cleanliness of the department as ‘very clean’
• 89% of patients ‘definitely’ felt involved in decisions about care and treatment.
• 98% of patients ‘always’ had enough privacy when discussing treatment and 99%
‘always’ had enough privacy when being examined.
• 98% of patients said they were ‘always’ treated with dignity and respect and 96% said
they were ‘definitely’ treated with care and compassion.
• 82% of patients rated the overall level of care as excellent, with 18% rating it as good.
For the patient this means that they can be confident in a high level of cleanliness, care and
compassion during their visit here.
Dementia CQUIN (Commissioning for Quality and Innovation)
One element of the dementia CQUIN standard is the requirement for the trust to undertake
monthly feedback among carers and relatives of people with dementia. A short questionnaire
has been developed to gauge how well relatives and carers feel staff understand dementia,
how involved they feel in their relative’s care and also to measure awareness of patient
passports.
44
During 2014/15:
•
92% of respondents felt their relative
‘definitely’ had enough privacy when being
examined or treated;
•
92% of respondents felt their relative had
‘definitely’ been treated with dignity and
respect;
•
74% of respondents felt that the staff
involved in their relative’s care ‘definitely’
knew how to care for someone with
dementia;
•
61% of respondents said that they
‘definitely’ felt involved in their relative’s
care with a further 33% saying they felt
involved ‘to some extent’.
“Hospital is a very distressing
experience, but I felt in safe hands. Thank
you.”
“All the medical and non-medical NHS
staff treated me professionally and with
care and respect. All have been kind
and knowledgeable in their fields.”
“Thank you for the excellent care and
attention I received during my stay in
A&E. I was treated with respect and
dignity at all times.”
Further information on dementia can be found on page 49 of this report.
2014/15 National Cancer Patient Experience Survey
The 2014 National Cancer Patient Experience Survey, sent to a sample 118,081 patients at
153 NHS trusts that provide cancer treatments, asked patients how they rated the care they
received. 229 patients from East Cheshire NHS Trust were sent a survey with 136 patients
responding, a response rate of 66%. The national response rate was 64%.
The trust was rated as one of the top five trusts in England and in the top 20% of trusts for
42 areas out of a possible 62. 92% of patients rated their overall levels of care as excellent
or very good.
For the patient this means the highest level of patient information, excellence in pain control
and the patient receiving personal individualised care. Areas of action and improvement
include patients being offered a written assessment and care plan
CQC National Emergency Department Survey 2014
East Cheshire NHS Trust was reviewed by 289 patients out of a random sample of 799
patients who attended the department in March 2014. Overall, the trust was classed as
performing in line with other trusts for all criteria included within the survey.
For the patient this means improved waiting times in the department and a shorter time
before speaking to a clinician and improved privacy and confidentiality at the reception area.
Actions for improvement include the availability of refreshments in the department and
improved patient information on leaving the department on the patient’s condition.
45
CQC National Adult Inpatient Survey 2014
East Cheshire NHS Trust was reviewed by 415 patients out of a sample of 810 patients who
had been treated as an inpatient at the trust during summer 2014.
Overall, the trust was classed as performing in line with other trusts for the majority of areas.
It was classed as performing better than other trusts in relation to hospital staff discussing
whether additional equipment or adaptations would be needed at home following discharge.
The trust showed an improvement in its scores for 27 areas. The areas where the trust’s
performance was most improved include:
•
•
•
•
Patients receiving enough help to eat meals
Staff discussing whether adaptation or equipment was needed after discharge
Clear written information given in relation to medication
Patients being told who to contact if worried following discharge
The trust was classed as performing ‘worse than other trusts’ for patients being disturbed by
noise at night from other patients and staff. A full action plan has been developed to address
these and any other areas where the trust feels it could improve its performance.
NHS Staff Survey
A sample of trust employees took part in the annual NHS Staff Survey, between September
and December 2014. Our response rate was 34%. When compared with acute trusts (a
comparison with combined acute and community trusts is not yet possible), we compared
favourably regarding:
 staff experiencing discrimination
 staff feeling pressure to attend when feeling unwell
 staff believing the trust provides equal opportunities for career progression
 staff appraisals – identified as one of the best 20% of acute trusts and staff
experiencing harassment, bullying or abuse
We compared less favourably in the following areas:
 work pressure felt by staff and staff suffering work-related stress
 staff reporting good communication between managers and staff
 staff agreeing their role makes a difference to patients
 staff working extra hours
We will aim to improve in these areas using methods including the trust’s staff engagement
programme - Your Voice; Listening into Action, and the trust’s wellbeing programme.
The staff survey has also highlighted a significant increase in staff reporting that the trust
provides equal opportunities for career progression and promotion. The trust is in the best
20% in this area. The trust has invested in is a range of leadership development
programmes accessible to staff across the whole organisation. These programmes have
provided an opportunity for staff to increase their knowledge, skills and competence in order
to prepare individuals for their next career move.
46
Audit participation
During 2014-15, 31 national clinical audits and four National Confidential Enquiries into
Patient Outcomes and Death (NCEPODs) covered NHS services that East Cheshire NHS
Trust provides.
During that period East Cheshire NHS Trust participated in 25 out of 31 (81%) of the national
clinical audits and four out of four (100 %) of the NCEPODs which it was eligible to
participate in.
The national clinical audits and national confidential enquiries that East Cheshire NHS Trust
participated in, and for which data collection was completed during 2014-15 are listed below
alongside the number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
National Audit
Neonatal intensive and
special care (NNAP)
(01/01/2014 to
31/12/2014)
Epilepsy 12 (Childhood
Epilepsy)
Paediatric Intensive
Care (PICAnet)
Diabetes (Paediatric)
Fitting child (care
provided in emergency
departments)
Chronic Obstructive
Pulmonary Disease
Acute Coronary
Syndrome or Acute
Myocardial Infarction
(MINAP)
Heart failure
Comparative audit of
blood transfusion
Participati
on
Data
collection
2014/15
Patient
recruited
2014/15
% cases
submitted in
2014/15
Y
Y
133
100%
Y
Y
8
100%
Y
Y
100%
Y
Y
14
Data
submission for
the 2014-15
National
Paediatrics
Diabetes Audit
(NPDA) opens
1st April 2015 29th June 2015.
Y
Y
29
Y
Y
42
Y
Y
On-going
Y
Y
On-going
Data
collection
commences
01/02/15
Expected
between 45-70
Y
All eligible patient
data will be
submitted.
100%
100%
Audit Period
01/02/2014 to
31/03/2014
Data completion
date end May
2015
Data completion
date end May
2015
Depends on
numbers submitted
over data
collection period
47
National Audit
Participati
on
Data
collection
2014/15
Patient
recruited
2014/15
% cases
submitted in
2014/15
Adult critical care
(ICNARC)
Y
Y
393
100%
Rheumatoid & early
inflammatory arthritis
Y
Y
46
98%
Emergency laparotomy
Two year data
collection period
Y
Y
From January
2014 to
February 2015
– 117 cases
entered
Y
Y
290
99%
Y
Y
223
100%
Y
Y
40
100%
Y
Y
245
100%
Y
Y
974
54.56%
Y
Y
45
100%
Y
Y
127
117.5%
Y
Y
147
100%
Y
Y
38
100%
Y
Y
68
136%
National Joint Registry
Falls & Fragility
Fractures Audit
Programme, includes
National Hip fracture
database
Inflammatory bowel
disease (IBD)
Stroke National Audit
Programme SSNAP
(combined Sentinel &
SINAP)
National Audit of
Intermediate Care –
South & Vale Royal
Bed-based services
Intermediate care at
home
Hospital at home.
Transitional health beds
Renal replacement
therapy (renal registry)
Lung cancer
Bowel cancer
Head & Neck Oncology
Oesophago-gastric
cancer
48
National Audit
Participati
on
Data
collection
2014/15
Patient
recruited
2014/15
Pre-operative
questionnaires
completed
605
Y
Y
108
Older People (care
provided in emergency
departments)
N
N
Mental Health (care
provided in emergency
departments)
N
N
N
N
N
N
N
N
Elective surgery
(National PROMS
programme)
Includes Groin Hernia,
Hip Replacement,
Knee Replacement &
Varicose Veins
TARN
% cases
submitted in
2014/15
Participation rate
Y
Y
77.4%
(data published on
13/11/14 for the
period April 13 to
March 14)
Post-operative
Response rate
Y
Y
questionnaires
64.2%
returned 326
(data published on
13/11/14 for the
period April 13 to
March 14)
The adjusted health gains demonstrate that we are not an outlier
nationally in any of the specific conditions/procedures, therefore
comparable to the national outcomes re: patient reported health
gains and improved quality of life post procedure.
49 cases
Y
Y
submitted for
Continuous data
the period April
input
to December
2014 – data
input on-going
Prostate Cancer
Pleural Procedures
Adult community
acquired pneumonia
Cardiac arrest
This audit does
not fall in line
with our current
ED practice
This audit does
not fall in line
with our current
ED practice
Minimum
numbers for
participation not
met
Advancing
Quality already
collect data therefore we do
not take part in
the National
Audit
N/A –
Extensive,
quality data
provided
through local
audit
100%
N/A
N/A
N/A
N/A
N/A
49
National Audit
Chronic kidney
disease in primary
care
Congenital Heart
Disease (Paediatric
Cardiac surgery)
Adult Cardiac surgery
Pulmonary
Hypertension
Cardiac arrhythmia
National Vascular
Registry, including CIA
and elements of NVD
Prescribing
Observatory for Mental
Health (POMH-UK)
Coronary Angioplasty
Adherence to British
Society for Clinical
Neurophysiology
(BSCN) and
Association of
Neurophysiological
Scientists (ANS)
Standards for Ulnar
Neuropathy at Elbow
(UNE) testing
Ophthalmology
Specialist
rehabilitation for
patients with complex
needs
Diabetes (adults
ANDA) includes
National Diabetes
Inpatient Audit
(NADIA)
Parkinson’s Disease
Familial
hypercholesterolaemia
National Audit of
Seizure Management
(NASH)
Adult bronchiectasis
Paediatric Pneumonia
(BTS)
National Audit of
Dementia (NAD)
Participati
on
Data
collection
2014/15
Patient
recruited
2014/15
% cases
submitted in
2014/15
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Data for East Cheshire NHS Trust
patients included in patient data
submitted by UHSM
The prospective phase of the audit will commence data collection
in September 2015
The Audit Management Organisation had not yet appointed @
06/02/2015
NADIA Steering Group advised there would be no data collection
during 2014
Healthcare Quality Improvement Partnership (HQIP) confirmed no
eligible data collection in 2014/15
HQIP advised not eligible for Quality Accounts 2014-15
Removed from Quality Accounts 2014-15
Removed from Quality Accounts 2014-15
BTS advised that the National Paediatric Pneumonia Audit had
been postponed and that the audit would not run in 2014/2015.
HQIP stated no data collection in 2014-15
50
Confidential
Enquiries
Child Health (CHRUK)
Maternal Infant and
Perinatal
(previously
Perinatal Mortality)
National
Confidential
Enquiry into Patient
outcome and Death
(NCEPOD)
Gastrointestinal
Haemorrhage
National
Confidential
Enquiry into Patient
outcome and Death
(NCEPOD) Sepsis
National
Confidential
Enquiry into Patient
outcome and Death
(NCEPOD) Lower
Limb Amputation
National
Confidential
Enquiry into Patient
outcome and Death
(NCEPOD)
Tracheostomy Care
National
Confidential
Enquiry into
Suicide and
homicide for people
with mental illness
(NCISH)
Participation
Data Collection
% cases submitted
N
N
No qualified cases
submitted
Y
Y
9/9
100%
Y
Y
5 qualified cases during
data collection period
Y
Y
4 qualified cases during
data collection period
Y
Organisational
questionnaire
returned. This
covered the
rehabilitation of
patients following
lower limb
amputation
No qualifying
amputations for the
data collection period
Y
Y
5 qualified cases during
data collection period
N/A
N/A
N/A
51
The reports of 16 national audits were reviewed by the provider and East Cheshire NHS Trust
intends to take the following actions to improve the quality of healthcare provided:
National Audit
Actions and Progress
Surgical
Specialties
National Emergency Laparotomy Audit
The aim of the audit is to enable the improvement of the quality of care
for patients undergoing emergency laparotomy through the provision of
high quality comparative data from all providers of emergency
laparotomy.
The audit is currently running over three years. In Year 1 an
organisational audit was performed, with individual patient data
collection in Years 2 and 3.
East Cheshire Trust has participated in the National Emergency
Laparotomy Audit since it commenced in 2013.
The Organisational Report of the National Emergency Laparotomy Audit
has been reviewed by the Surgical Team and patient data continues to
be input during the data collection period.
Women’s and
Children’s
Newborn Hearing Screening: Parent Satisfaction Audit 2014
This is the sixth Macclesfield NHSP Parent Satisfaction Audit, since the
Macclesfield Newborn Hearing Screening Programme (NHSP) began in
February 2004, as part of Phase 3 of a national five-phase rollout.
The NHSP National Quality Standard concerning coverage and
timeliness specifies that 95% of all babies should have completed the
screen process by the 28th day of life and this Standard is regularly
achieved at Macclesfield. Just under 80% of babies born at Macclesfield
hospital have their screen completed as inpatients.
Home births, babies born at other hospitals and babies requiring a
further screen are seen as outpatients in a screening clinic which runs
once a week in Children’s Outpatients.
Headline conclusions:




Quality Standards for coverage and timeliness are achieved.
Consistent and ongoing high standards of performance.
Responses received for “overall rating” were reported as 98%
rating the process as Excellent and 2% as Good
Skills, knowledge, approachability and competence are
perceived as “Excellent” by parents.
52
National Audit
Actions and Progress
Clinical Support
& Diagnostics
National Care of the Dying Acute Hospitals (NCDAH) Audit Round 4
The NCDAH is prepared by the Royal College of Physicians (RCP) in
collaboration with the Marie Curie Palliative Care Institute Liverpool
(MCPCIL).
It reflects many of the issues identified in the Independent Review of the
Liverpool Care Pathway (LCP) as well as what needs to be done to
improve the quality of hospital care for dying people and their families.
The audit aims to contribute to learning that can help to improve the care
for dying patients and their relatives or carers in hospital settings.
The standards of care evaluated in the audit were based on The End of
Life Care Strategy and reflect recent national policy guidance, including:
• Best care for the dying patient
• NHS Constitution
• NHS Outcomes Framework
• The NHS Mandate
• National Institute for Health and Care Excellence (NICE) Quality
Standards
• The Care Quality Commission (CQC) Essential Standards of
Quality and Safety
• End-of-Life Care Quality Markers
• Guidance for doctors
Where the organisational audit highlighted gaps, actions have been put
in place to close the gaps. Key findings from the case note review
highlighted that East Cheshire achieved higher than the national score in
approximately 50% of the key performance indicators (KPIs). However,
when compared with the other Cheshire and Merseyside Strategic
Clinical Networks trusts’ performance, East Cheshire was the only trust
not to achieve the national benchmark of 55% for the summary KPI for
the domain ‘Discussion about senior doctor decision held with patients
capable of participating’. A closer examination of the East Cheshire
scores suggests that this was partly caused by the lack of evidence of
discussions with patients and relatives/friends.
Bereavement survey questionnaires were returned by 27 relatives (41%
response rate). Confidence in the team scored highly along with
nurses/doctors having time to listen/discuss the patient’s condition with
relative.
National recommendations have been published and we plan to take
the following actions:1. Introduction, education and roll out of Care Plan for End-of-Life
Care- emphasis on documentation of communication.
2. Maintain end-of-life care sessions within mandatory training
3. Extend end of life training to trust induction and to non- qualified
staff members.
4. Continue to explore seven day 9am – 5pm service for specialist
palliative care.
5. Develop and launch written information to support visiting
relatives to access facilities.
6. Ensure annual audit is completed including survey of bereaved
relatives and reported at Board level.
7. Get end-of-life care represented as a standing agenda item at
relevant committee.
53
National Audit
Actions and progress
Urgent Care
Paracetamol overdose – The data for this audit was collected in August
and September 2013. Local findings were presented within and outside
the Emergency Department. This has included presentations to the
Emergency Department juniors, the medical meeting and Grand Round
lectures as well as to various medical students and members of nursing
staff.
The department performs well at:
 Recording size of ingestion.
 Testing patients in whom paracetamol levels will direct
management.
The department showed an improvement on a background of national
cohort worsening performance in treating patients with single acute
overdose within eight hours of ingestion.
The department, in common with most participating departments,
performed poorly with patients in whom treatment is commenced on
clinical grounds:
 Single acute overdose presenting beyond eight hours from
ingestion.
 Staggered overdose
Action taken:
 Education of medical and nursing staff.
 Update of the NAC prescribing tool to include time of prescription
as well as time of administration
Recommendation:
Steps are needed to improve the timeframe within which patients
presenting with an indication for immediate treatment, i.e. later
presentation and staggered overdose, are identified, triaged, assessed
and treated.
The information to make this decision appears to be already gathered at
triage – we sit in the top quartile of departments for recording time of
ingestion. Delayed presentation of staggered ingestion need to be
identified and these two groups of patients brought to the early attention
of medical staff for immediate treatment.
Possible future development:
Patient Group Directive for treatment of two groups of patients by nurse
prescriber on presentation and prior to medical assessment:
 Staggered overdose taking more than 6g or 75mg/kg in total.
 Single acute overdose taking more than 6g or 75mg/kg more
than seven hours earlier.
54
National Audit
Actions and Progress
Medical
Specialties
Acute Kidney Injury (AKI) following the NCEPOD “Adding Insult to
Injury” report published in 2009, East Cheshire NHS Trust produced an
AKI pro-forma. Following implementation of the pro-forma an audit was
undertaken in 2010 with re-audit in 2011.
Recommendations included:• Updated and wider use of AKI pro-forma as per NICE guidelines.
• Further education for junior doctors, pharmacists and nursing
staff to raise awareness of the recommendation for cessation of
nephrotoxic medication, renal USS and catheterisation of
patients with AKI.
• Continue to encourage timely identification and risk assessment
of patients with AKI
Selected trusts that utilised the AKI pro-forma were invited to participate
in a national survey during 2012/13 to assess the current management
of patients with AKI and East Cheshire NHS Trust took part.
Conclusions from the audit reported:
• East Cheshire NHS Trust is meeting the national average for the
majority of components measured during AKI study
• Increased use of AKI pro-forma on clerking patient
• Failing on select few
Next steps:• Update the AKI pro-forma, according to the NICE
guidance CG169 Acute Kidney Injury published in August 2013
• Re-audit planned for January 2015
Allied Health
Services
An audit of performance against Commissioning for Quality and
Innovation (CQUINS) linked to the Specialist Community Stroke
Rehabilitation team has commenced in 2015.
The aim is to audit compliance with the CQUIN on a quarterly basis,
providing supporting evidence for the commissioners in order to achieve
the linked financial allocation.
The changes in practice that will be achieved are:
1. Provision of information and advice to stroke patients and
their carers to support secondary prevention and selfmanagement.
2. Provision of patient passports to stroke patients to support
communication of the personal needs of patients
55
National Audit
Actions and Progress
Integrated Care
The South and Vale Royal Intermediate Care Service has participated in
the National Intermediate Care Audit since 2010 and presented findings
from the 2014 audit at the Integrated Care audit meeting.
Two of the areas that patients were asked to feedback on were;
 Quality of service provided for bed-based service and
 Home-based services.
Results show that South and Vale Royal achieved 100% for the five
questions and statements below, which for each question, is above the
national average.
Q. Do you feel that there is something that could have made your
experience of the service better?
Q. I was aware of what we were aiming to achieve e.g. to be
independent at home, able to go shopping
Q. The length of time I had to wait for my care from the team to start was
reasonable.
Q. I had confidence and trust in the staff treating or supporting me.
Q. Overall I felt I was treated with respect and dignity while I was
receiving my care from this service.
56
The reports of two NCEPODs were reviewed by the Board, along with the protocols of three
NCEPODs. East Cheshire NHS Trust intends to take the following action to meet the
recommendations and requirements of each study. (We have taken into account the
devolvement of responsibilities to other trust committees/groups and included actions
informed by those bodies.)
Group or forum
National audit reviewed
Actions and progress
CARE Group (Clinical Audit
Research and Effectiveness
Group) monthly meetings
The following NCEPOD
studies were reviewed by the
CARE Group during 201415:-
GI Haemorrhage study
discussed at the January and
February CARE Group
meetings. Trust NCEPOD
reporter gave assurances
that the dataset had been
completed and returned to
NCEPOD within timescales
set.



GI Haemorrhage
Study
Sepsis Study
Acute Pancreatitis
Study
The following NCEPOD
reports were reviewed by the
service lines during 201415:

Tracheostomy Care:
On the Right Trach?
Lower Limb
Amputation: Working
Together
Sepsis study discussed at
the May and August CARE
Group meetings. Trust
NCEPOD reporter had
disseminated the paperwork
to nominated lead for the
prospective data collection to
take place during 6th to 14th
May 2014. Questionnaires
disseminated to relevant
consultants during August
and all questionnaires
returned by deadline,
following national extension
to timescales.
Acute Pancreatitis study
discussed at the December
Care Group. Trust NCEPOD
reporter liaised with the
Information department to
request the data for the
patient identifier
spreadsheet.
57
The reports of 120 local clinical audits were reviewed in 2014-15 and East Cheshire Trust
intends to take the following actions to improve the quality of healthcare provided. (We have
taken into account the devolvement of responsibilities to other trust committees/groups and
included actions informed by those bodies)
Group or forum - CARE Group (Clinical Audit, Research and Effectiveness Group)
Monthly meetings.
Local audits reviewed - Clinical Records Management Audit and Re-audit
Actions and Outcomes





CARE Group reviewed the results of the annual Clinical Records Management Audit
conducted in spring 2014 and reported that all three business groups had achieved
an increase in overall compliance compared with previous audit. The group agreed to
carry out a re-audit in September 2014 for those specialties that had not achieved
75% compliance.
The re-audit was carried out on 180 sets of case-notes across the service lines and
compliance had increased in 70% of the criteria that have been re-audited across the
service lines.
One of the key issued identified related to the recording of alterations/deletions.
Action taken included a review of the policy; which has made it clear as to what
constitutes an alteration/deletion and the distinction between a minor alteration and a
major change. This policy update has been disseminated as relevant and reviewed
by the CARE Group members.
The Clinical Records Management audit reports have been shared with the service
line SQS Committees, to agree action plans with timescales for implementation.
Any outstanding actions will be raised via the CARE Group quarterly reports to the
trust’s SQS Committee.
.
58
Group or forum - Departmental Audit meetings Surgical Specialties
Local audits reviewed - All of the audits have actions plans for development or have
achieved the standards of care. Audit of wound infection following elective upper limb
surgery between January 2012 and June 2012.
Actions and Outcomes
 To investigate the incidence of wound infection following elective upper limb surgery
between January and June 2012 and the improvement of patient care by minimising risk
of infection
 Standards of measurement: Incidence of infection in 3 previous departmental audits:
0.7%- 3.4%
 Incidence of infection reported in literature: 0.1%- 5%
 The incidence of wound infection following elective upper limb surgery between January
and June 2012 was only 1.16%, which meets the local and international standards.
59
Group or forum - Clinical Support & Diagnostics. Audits have been undertaken by the
pharmacy department and presented throughout the trust. We have included best practice
examples.
Local audits reviewed All of the audits have actions plans for development or have
achieved the standards of care. Audit to demonstrate the trust’s compliance with National
Patient Safety Agency (NPSA) Patient Safety Alert 20: Promoting Safer Use of Injectable
Medicines.
Actions and Outcomes
An observational audit of intravenous medication administration was carried out across the
trust to ensure compliance with NPSA 20 recommendations.
Observations were carried out over a four-month period by the Clinical and Professional
Training Manager, of healthcare professionals administering intravenous medications.
Results:
The standards required to safely administer an IV medication were followed in the majority of
observations.
Actions:
 Ensuring all syringes, including flushes, are labelled.
 Explaining to the patient, treatment and potential side effects.
 Checking of documented allergy status on front of drug chart prior to medication
administration.
Actions from the audit have been assigned to the matrons and unit managers and the
service line leads will oversee the completion of all actions identified
60
Group or forum - Women’s & Children’s
Local audits reviewed All of the audits have actions plans for development or have
achieved the standards of care. (Snapshot VTE Audit on Maternity Ward and Audit of the
NICE Clinical Guideline CG160 Feverish Illness in Children)
Actions and Outcomes
The aims of this audit were to measure how the Maternity Department performs, in
comparison to that of different departments within the trust, regarding VTE assessments and
prescribing.
The VTE process in Maternity is slightly different from that in the rest of the hospital due to
alternative guidelines, risk factors and procedures. Trust-wide, the VTE is assessed by the
doctors, whereas most of the time the VTE is assessed by the midwives who have an active
role for the entire duration of these patients’ pregnancies.
This audit was performed by a foundation year two doctor as a snapshot audit covering two
days. Data was collected on 17 patients on the postnatal ward.
Results:
The department achieved 100% in several of the criteria measured including:
 Initial assessment at both antenatal and postnatal
 Provision of TED stockings to all risk patients
 All the patients were assessed for the right dosage of Tinzaparin according to weight
Actions:
 Re-assess the VTE 24 hours post-admission of any maternity patient
 Ensure the prescription for the Tinzaparin post re-assessment is done.
Audit of the NICE clinical guideline CG160 feverish illness in children
Aims of the audit:
• To determine whether we are following the NICE recommendations for the
management of children aged under five, presenting with a fever of unknown cause.
• Aiming to improve the paediatric management of these children.
Results:
The department achieved 100% in several of the measured criteria including:
 Immediate life-threatening features identified
 Assessed in accordance with traffic light system
 Those who need parenteral antibiotics receive third-generation cephalosporin
NB: no children aged under three months were included, due to random sample and proforma automatically calculated results without taking into account other factors.
Actions:
 Re-audit be carried out on a prospective basis, on children with fever presenting to
children’s ward;
 Re-audit sample to include 50% patients aged under three months and 50% aged
over three months.
61
Group or forum – Urgent Care
Local audits reviewed All of the audits have actions plans for development or have
achieved the standards of care. Delirium in Critical Care
Actions and Outcomes
Aims of the audit:
To evaluate the recognition, prevention and management of patients at risk of delirium,
following a drive to improve awareness among the nursing staff and changes to
documentation that took place in 2013. The audit criteria and standards were based on the
recommendations from NICE clinical guideline 103.
Results:
Delirium is a common condition associated with poor outcomes. All patients admitted to the
Intensive Care Unit (ICU)/High Dependency Unit with a severe illness are at risk of delirium.
Age, existing cognitive impairment and recent hip fracture compound that risk. This risk is
not always documented.
All patients identified at risk of delirium should be screened and managed appropriately.
Interventions to prevent and manage delirium are rarely documented.
The clinical guidelines on the pharmacological management of patients with delirium are not
always referred to.
Actions:
Assessment
 Assess people at risk of delirium every eight hours using confusion assessment
method (CAM)-ICU
 Embed delirium assessment into documentation by medical staff
Education
 CAM-ICU Diagnostic tool
 Non-pharmacological prevention and treatment
Medication
 Doctors to be aware of the prescribing criteria for delirium
Documentation
 Ensure pathway is completed
 Embed daily routine discussion of delirium assessment by consultant
Future
 Produce information for relatives/carers
 Review the use of physical restraints
 Provide a multi-component intervention package to prevent and treat delirium
 Re-audit in 2015 to ensure continued good practice and 100% compliance is
achieved in all areas
Actions from the audit have been assigned and reviewed by the service line’s Safety Quality
Standards Committee.
62
Group or forum – Medical Specialties
Local audits reviewed All of the audits have actions plans for development or have
achieved the standards of care. Audit to review the safe prescribing and administration of
insulin.
Actions and Outcomes
Aims of the audit:
To review the safe prescribing and administration of insulin, by assessing the standards
below. (The audit also reviewed ward nurses awareness of the Health and Safety (Sharp
Instruments in Healthcare) Regulations 2013.
 Prescriber to sign and date
 Prescribers printed name, ID badge number and signature
 Type of insulin, brand and device
 Use ‘units’ in full, not ‘u’ or ‘iu’
 Insulin administered by pen or insulin syringe
 Supply of insulin syringes in all areas
 Understanding of safe disposal of insulin needles
Standards met:
 Staff knew to use the insulin syringe to measure and prepare insulin
 All wards in Macclesfield Hospital keep stock of insulin syringes.
 All staff knew to use the sharps bin as written in the Policy for the Safe Administration
of Insulin 2
 No prescription for insulin had abbreviated ‘units’
Improvement needed:
 16/18 prescriptions failed to meet all the criteria recommended by the NPSA and in
the trust’s Medicines Policy
 There was lack of awareness of how to safely remove insulin pen needles/
compliance with the Health and Safety (Sharp Instruments in Healthcare) Regulations
2013
Actions:
Ensure prescribers are aware of the audit results and must include their signature, printed
name and id number when prescribing medication (including insulin) on patients’ drug
charts. They must also include the type of insulin device.
All insulin prescribing errors are recorded on Datix and where they can be, reviewed by
service line leads and the Safe Medicines Group.
The Task and Finish group is developing a policy for safe insulin pen needle disposal. This
policy will be disseminated to all staff responsible for insulin administration and there will be
training for staff on the use of safer sharps for insulin pen needles.
63
Group or forum – Allied Health Services
Local audits reviewed All of the audits have actions plans for development or have
achieved the standards of care
DEN03 – Management and decontamination of surgical instruments (medical devices) used
in acute care.
Actions and Outcomes
The 2014 annual dental audits were completed and submitted with scheduled follow-ups.
Compliance issues included; expansion to create additional decontamination room at one
site, along with facilities/equipment at two further sites.
Action plans where appropriate have been put in place.
All sites did fulfil the 'Essential' criteria but implementation of the actions would achieve 'Best
Practice' at the identified sites.
64
Group or forum – Integrated Care
Local audits reviewed - All of the audits have actions plans for development or have
achieved the standards of care. Audit on the Effectiveness of Prophylactic Proton Pump
Inhibitors for Prevention of NSAIDs Associated Gastric and Duodenal Ulcers in Elderly
Actions and Outcomes
Aims of the audit: Chronic non-steroidal anti-inflammatory drugs (NSAIDs) are associated
with gastric and duodenal ulcers, especially in vulnerable elderly patients.
The audit aimed to ensure that all elderly patients, who are taking NSAIDs on a regular basis
are prescribed prophylactic proton pump inhibitors (PPIs) and are aware of the benefits and
risks of these medications, to prevent development of upper gastrointestinal symptoms and
ulcers.
Results:

A total of 386 patients on NSAIDs were included in the audit on April 2014.

273 (71%) patients were prescribed concomitant prophylactic PPIs.

113 (29%) patients were not on PPIs, of them 90 (23%) patients were excluded.
Actions:
Postal letters were sent for the 23 (6%) patients who were prescribed NSAIDs without
prophylactic PPIs. The 23 patients were seen in the practice, where the benefits and risks of
concomitant use of PPIs were discussed and PPIs were prescribed.
A re-audit was done 12 weeks later.
Re-audit recommendations:



A change in practice was made after the initial audit by Prescribing Prophylactic PPIs
for patients who were prescribed regular NSAIDs without concomitant PPIs.
After the re-audit it was recommended to: Continue the same practice, arrange an
educational session for junior doctors to increase their awareness of factors
contributing to NSAID-induced GI complications, particularly with respect to
advanced age.
Re-audit to be done 12 months later.
65
Audit examples of good practice
Surgical Specialties
Midazolam Usage for Sedation in Adults
Sedation is widely used in medical practice. Avoidable mortality and morbidity continues to
happen despite multiple sets of recommendations and research.
The principal aims of the audit is to provide assurance that conscious sedation using
midazolam is being performed safely and effectively at East Cheshire NHS Trust and that the
recommendations of the National Patient Safety Agency (NPSA) Rapid Response Report
entitled “Reducing Risk of Overdose with Midazolam Injections in Adults”
(NPSA/2008/RRR011) [4] is being adhered to.
Our audit confirmed that the governance arrangements surrounding procedural sedation and
in particular the administration of midazolam are good. In particular, we are fully compliant with
all the recommendations of NPSA/2008/RRR011.
There are a number of different standards relating to midazolam administration. This likely
reflects its usage by a number of different specialities for a variety of different indications.
We extracted the standards that we felt to be of most importance and based our audit on
these. Overall the compliance was excellent, with only minor aberrations which are highlighted
in the recommendations and action plan.
Recommendations:
• Action taken to ensure that all patients are given a leaflet explaining their sedation before
they leave hospital
• Staff reminded to record any usage of flumazenil to reverse over-sedation on the trust’s
incident reporting system, Datix.
66
Clinical Support and Diagnostics
Audit of Inclusion of Estimated Glomerular Filtration Rate (EGFR) on Outpatient
Computerised Tomography (CT) Requests
The aim of the audit was to compare local provision of accurately-dated EGFR provision on
CT request forms against Royal College recommendations and to examine the consequences
of failure to meet these guidelines on Radiology workflow and manpower resources.
The use of intravascular contrast agents has increased dramatically in recent years. The
potential risks of intravascular administration of contrast agents must be weighed against the
potential benefits - acute renal failure is serious and costly. Nephropathy induced by contrast
medium (CIN) remains one of the most clinically-important complications of the use of
iodinated contrast medium.
Patients with EGFR < 45 ml/min are at progressively at increased risk of CIN which may invert
the risk-benefit of proceeding with contrast-enhanced CT. Knowledge of recent EGFR is
essential in risk stratification of patients and accurately-dated measurements are required on
CT request forms as stated in current CT Standard Operating Procedure to clinical referrers.
Although all the patients in this audit had EGFR tests performed in a timely manner, only 16%
of requests included these with relevant date on the form. 26% of patients have no EGFR
result at time of request. Both of these issues combine to require CT staff to manually look up
biochemistry results and accounts for eight full working days per year of lost superintendent
radiographer time.
Findings from the audit as follows:
•
•
•
•
100% of patients had timely EGFR measurement at the time of CT contrast injection.
26% of patients did not have timely EGFR at time of making CT request requiring
multiple checks until these results become available.
16% of 100% target achieved for these results to be included with accurate date on CT
request form.
Eight full working days of CT superintendent time lost per year spent looking up these
omitted results.
Recommendations:
•
•
•
Clinician refresh regarding existing standard operating procedure with respect to results
being available at time of request, and including these along with date on the request.
Present this audit data at Grand Round.
Adhere more strictly to existing standard operating procedure for outpatient CT with
respect to thorough form-filling to avoid significant loss of senior radiographer time.
67
Women’s and Children’s
Annual Maternity Safeguarding Audit
The objectives of the audit were to maintain, improve and monitor:
•
•
•
frontline practice
information sharing
joint working
In line with Department of Health Working Together March 2014 methodology:
•
20 sets of hospital records were selected concerning babies delivered between April
2013 – April 2014, where safeguarding issues had been identified by midwifery staff.
The aims of the audit:
•
•
•
To ensure that midwifery staff were working within the trust’s Safeguarding Policy and
guidelines
To ensure information had been shared with health colleagues and partner agencies
Ensure that the ‘voice of the child’ was being considered and documented
Recommendations:
•
•
•
•
•
Improvements to be made in the documentation of postnatal care on the cause for
concern form. This needs to be as contemporaneous as possible
Multi-agency referral form to be filed in hospital records
Safeguarding supervision to be undertaken every three months with the team leaders
and ANC manager
All child protection concerns to be notified to the named midwife
All child protection concerns to be communicated with universal health services, eg GP
and health visitor.
Actions from the audit have been assigned to the named midwife for safeguarding and
antenatal team and will be monitored at maternity clinical governance meetings.
68
Urgent Care
Quality Improvement Project - Improving Medical Handover Project
Drivers:
• Patient safety
• Regional disparity
• Increasing out-of-hours activity
• Team communication
• National guidance
• Lack of documentation
RCP Handover Recommendations (Toolkit 1 2011) Structured Clinical Handover should:
• Be embedded in hospital culture and multidisciplinary teams
• Involve training in handover and communication
• Define who should be present
• Be tailored to individual hospitals/units
The project included four phases. Conclusions Phase I:
• We need a formal structured handover protocol
• We should introduce consultant-led morning handover
• We need to start keeping auditable documentation
• We need to ensure adequate training in handover for new doctors
Recommendations Phase II:
• Design a structured standardised handover protocol
• Implement changes from Wednesday April 2nd 2014
• Introduce daily morning handover with consultant presence
• Auditable documentation
• Handover education for new doctor induction
• Continue to build business case for electronic handover
Implementing change Phase III:
• Morning handover successfully introduced on rotation day
• Publicity via emails, medical staffing, daily presence, specialist registrar engagement
• Consultant presence, SpR-led
• Standardised handover protocol introduced twice daily
• Audit sheets
Resurvey/Audit Phase IV:
• June 2014 (two month post-implementation)
• Same themes resurveyed
• Similar number respondents
• Comparisons made with Phase I survey
• Audit sheets all collected: 98% compliance recorded
The next phase:
Sustaining change – embedding culture (clinical champions),
Encouraging timely handover, handover in medical induction
ExtraMed (Hospipaedia) developing electronic admissions lists – functionality for
documentation and task distribution during handover process
• Improved auditability
• Improved accountability and information governance.
•
•
•
69
Medical Specialties
Warfarin prescribing for atrial fibrillation (AF) in stroke patients
All patients admitted with stroke and atrial fibrillation (AF) should have oral anticoagulants
prescribed. Any contraindications should be documented and oral antiplatelet therapy
commenced.
Methodology:
• Retrospective assessment of 261 patients admitted with stroke from 1/1/13 – 27/10/13
• Patients with a clinical coding of AF upon discharge were identified
• Review of all electronic discharge notification forms (eDNF) to see whether warfarin
prescribed
• If no reason documented – patient notes were reviewed
• Results were tabulated
Results:
• 51 patients were identified between 1/1/13 – 27/10/13
• 31 (61%) of patients were prescribed warfarin on discharge
• Of the 20 patients not prescribed warfarin all had valid reasons documented
• 15 patients were placed on antiplatelet therapy
• The remaining five patients not on antiplatelet therapy had reasons documented
Recommendations:
• Extend audit to other wards in Macclesfield District General Hospital
• Medical staff education – audit presented to medical students, foundation year doctors
and core trainees.
• Produce laminated sheets on the work stations to remind the discharge doctor to ensure
patients with AF and stroke are risk stratified, oral anticoagulants offered and
contraindications offered.
• Add a specific section on the eDNF to remind doctors to risk stratify patients in AF and
offer anticoagulants
Compared to the 2011 audit we have shown an improvement in practice.
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Integrated Care
Acute Trimethoprim Deficiency (in the elderly)
The aim of the audit was to evaluate whether we are following SIGN guidelines for the
diagnosis of urinary tract infection (UTI) – specifically in the elderly. SIGN guidelines state
“For inpatients over 65 years of age, diagnosis should be based on a full clinical
assessment, including vital signs”.
Methodology:
• Patients over the age of 65
• All patients had a diagnosis made of UTI either on admission or during hospital stay
made by medical consultant.
• All patients were started on antibiotics to treat UTI
• Catheterised patients excluded once audit started
BMJ guidance states: “If a dipstick test has been done it should be considered useful only if
the result is negative and no clinical features of urinary tract infection are present, thus
excluding the latter. We do not recommend using urine dipstick tests to rule in the diagnosis of
urinary tract infection in older people, on the basis of the evidence available from prospective
studies and guideline recommendations”.
Results:
•
•
Of the 32 patients included in the audit, 15% met SIGN UTI diagnostic criteria, 85% did
not meet the criteria.
90% of patients had diagnosis made/confirmed on urine dipstick, which is inappropriate
according to SIGN and BMJ guidance
Recommendations:
•
•
•
•
•
Urine dipsticks are not to be used to confirm diagnosis of UTI in the over 65s
Do not treat as UTI unless they meet diagnostic criteria
Caveat - If it is felt that a UTI is likely even when diagnostic criteria not met (history
unobtainable) then check white cell count ( WCC) and c-reactive protein (CRP)
Observe the patient if unsure
Chase up the results of the mid-stream specimen urine (MSU)
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Corporate
New Unified DNACPR Policy
The objective for the interim audit was to measure compliance against the Unified Do Not
Attempt Cardiopulmonary Resuscitation (uDNACPR) Adult Policy, published in August 2014.
Comparisons with previous audits are not reflected, due to the fact the NHS North of England
North West Unified DNACPR Adult Policy audit tool differs from versions previously used by
ECNHST.
Methodology
•
•
•
•
A standardised uDNACPR audit tool was used for the audit to assess whether East
Cheshire NHS Trust policy was being followed in relation to uDNACPR decisions.
A prospective study of 20 inpatients at Macclesfield District General Hospital (MDGH)
with a uDNACPR order in place was undertaken.
The audit was conducted by the resuscitation officer over a period of two days.
As with previous audits, this audit assessed the adequacy of the documentation not
the appropriateness of the uDNACPR decision.
Results:
Overall the audit demonstrated relatively good compliance with the uDNACPR Adult Policy,
however the areas below require further improvement:-.
•
•
•
•
•
•
A summary of communication with the patient, or details as to the reason
communication cannot take place, needs to be significantly improved.
A summary of communication with the patient’s relevant other, or details as to the
reason communication cannot take place, needs to be significantly improved.
An improvement regarding consultant review/endorsement within the designated
timescale needs to be made.
Clinicians need to improve compliance with completion of the ‘review’ section.
A significant improvement needs to be made in relation to ensuring the registered
nurse responsible for the patient’s care is informed of the decision and signs the
uDNACPR order in the relevant section.
An improvement needs to be made regarding filling in the uDNACPR order
completely and ensuring an entry detailing the uDNACPR decision is made in the
medical notes. This entry must include details of discussion with the patient and/or
relevant other or reasons as to why such discussions could not take place.
.
The report including action plan has been issued trust-wide to the chief executive, interim
medical director, Resuscitation Committee, heads of services, clinical directors, clinical
tutors, Corporate Affairs and Governance Directorate and matrons. This will inform the audit
results and required actions necessary to improve compliance. The re-audit is planned for
May 2015.
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Participation in clinical research
Participation in clinical research demonstrates the trust’s ambition to improve the quality of
care offered and make a contribution to wider health improvement.
Our clinical staff stay abreast of the latest treatment possibilities and active participation in
research leads to successful patient outcomes. While maintaining the studies and following
up participants recruited in previous years, a further 22 studies have been opened and 133
participants recruited to them in 2014/2015. These studies can either be approved by the
National Institute of Health Research (NIHR) or other research studies including clinical trials
conducted with external companies.
The trust is currently involved in clinical research studies of which the majority are portfolio
studies covering a variety of medical specialities. Cancer services make up a large part of
our portfolio which mirrors the situation nationally. The cancer unit runs a number of trials
across a range of disease groups.
Oncology research
In 2014 the oncology research team at Macclesfield District General Hospital were the top
recruiting site for an academic breast cancer study called POETIC, which recently closed to
recruitment.
The POETIC (Perioperative Endocrine Therapy – Individualising Care) trial is a randomised
phase III multi-centre trial in postmenopausal women with ER/PgR positive invasive breast
cancer. The primary aim is to determine whether two weeks’ perioperative aromatase
inhibitor therapy before and after surgery improves outcomes compared with standard
adjuvant therapy.
Out of the 130 sites recruiting, Macclesfield was the top recruiter, entering 147 patients into
the trial, even beating the Royal Marsden Hospital, which sponsored the trial.
The success of the trial was as a result of:
•
•
•
•
The time taken initially to set-up the trial by educating and informing staff in various
departments.
Getting the relevant departments on board to support the trial: e.g. radiology for
identifying patients, pathology for sending off tumour blocks early to determine
eligibility.
Having the research team situated in the heart of the cancer resource centre where
we work alongside the clinics.
Having a research nurse attend every breast multidisciplinary team meeting to
identify further patients.
.
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Quality Priorities
2015/16
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Quality Strategy
The Quality Strategy demonstrates our commitment to deliver safe, effective and personal
care, working in partnership to develop innovative and integrated ways of working that drive
quality improvement. This will support the trust in achieving its vision and strategic
objectives.
We aim to strengthen out of hospital care, enabling more patients to receive high-quality
care in their own homes, in a community or domiciliary setting. Length of stay in hospital
wards will continue to reduce, as a result of evidence-based enhanced recovery approaches
for elective procedures, more timely discharge processes for complex elderly care and
improved technology that safely supports remote monitoring.
We will ensure staff have the necessary knowledge, skills and competence to provide the
best care in the best place for patients, listening and responding to individual needs and
preferences. To fully achieve our ambition we need to work in a more integrated way.
We aim to ‘join up’ care more effectively by working in formal partnership with our
commissioners, social care and other health providers through the Caring Together
Programme in Eastern Cheshire and the Connecting Care Programme in South Cheshire
and Vale Royal. We will build on our shared understanding of the needs of our population to
strengthen services, co-designing quality standards for our community services, placing the
patient at the centre.
Services will need to adapt and transform to meet the changing needs of our population. We
will therefore continue to strengthen professional leadership, motivating and empowering
doctors, nurses, midwives and allied health professionals to lead and deliver quality
improvements.
Our explicit commitment to the national ‘Sign up to Safety’ campaign will further strengthen
our focus and drive for harm-free care for all our patients within a culture of openness and
transparency, learning and continuous service improvement.
The Quality Strategy is ambitious and achievable. It has been developed with service users,
our staff and partners and embeds the values and behaviours we expect throughout every
aspect of our work with a clear focus on safe, effective and personal care.
We look forward to seeing the positive and continuous improvement in patient outcomes,
experience and performance metrics for the benefit of our patient population.
The Quality Strategy 2015-2019 supports the Clinical Service Strategy which aims to ensure
that we deliver the best care in the right place for patients. This will effectively move some
patients away from hospital care into more appropriate clinical care settings.
Quality care must be safe, clinically effective and provide a positive patient experience,
wherever that care is provided.
For East Cheshire NHS Trust, quality encompasses four elements:
1. Harm-free care - care that is safe
2. Improving outcomes - care that is clinically effective
3. Listening and responding - care that provides a positive experience for patients,
carers and families
4. Integrated care - care that is co-ordinated and based around individual needs
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This strategy is designed around these principles and our aspirations, building on existing
work that the organisation and staff have undertaken and sets out the priorities for the period
2015 - 2019.
Our focus is on helping people to stay healthy and independent by providing support and
services that prevent ill health and maintain quality of life. This approach of prevention and
early intervention will help people maintain control of their lives and decrease their
dependency on care services.
For young people we will continue to contribute to the public health agenda with a focus on
improving the health of children and young people, through the early help programme,
engaging families and carers in preventing ill health and maintaining wellbeing.
For those people who need care services as they grow older these services will be provided
to offer patient choice wherever possible, allowing them to maintain dignity and respect and
enable people to return to independence in their daily lives. The aim is therefore to provide
as much care out of hospital as possible designing and improving services that build on work
already happening in community and practice settings.
Our staff commitment to quality
Staff pledge - “We will care with compassion, ensuring we
communicate effectively, have the necessary competence to
understand your health and social care needs and the courage to
speak up for you.“
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Quality improvement
What are we trying to accomplish?
We aim to reduce avoidable harm by 50%, to achieve the highest possible consistency of
clinical care with better than expected mortality and to be in the top 20% of trusts for patent
experience.
• No avoidable deaths
• Continuously seek out and reduce patient harm
• Achieve the highest compliance with evidence-based care bundles (Advancing Quality
Programme)
• Deliver what matters most, working in partnership with patients, carers and families to
meet their needs and improve lives
• Deliver integrated care close to home which supports and improves health, wellbeing
and independent living
What have we achieved so far?
• Top five trust in the Patient Cancer Survey 2013/14
• First hospital in England to receive the National Autistic Society’s Autism Access Award
• 87% of patients who expressed a preferred place of care achieved this in 2013/14
• 35% reduction in complaints
• 24% increase in compliments
• 20% increase in number of staff volunteers
• Improved awareness and community pilot of patient passports for long-term conditions
• 97.5% inpatient responses ‘highly likely or likely’ to recommend to friends and family
• 97.7% compliance with venous thromboembolism prophylaxis standard for all hospital
admissions
• 79.1% breastfeeding initiation
• Rolled out electronic patient record system for community services (EMIS Web)
• Implemented enhanced recovery for major bowel surgery and hip and knee surgery,
improving patient mobility and reducing length of stay by more than 50%
• Rolled out electronic recording of bedside observations on all acute ward areas
• Implemented a tool to measure the safety culture
• Adopted the NHS change model to plan, spread and sustain quality improvement
Measuring the safety culture
The Manchester Patient Safety Framework (MaPSaF) is a tool to help NHS organisations
and healthcare teams assess their progress in developing a safety culture. MaPSaF uses
critical dimensions of patient safety and for each of these describes five levels of
increasingly mature organisational safety culture. The dimensions relate to areas where
attitudes, values and behaviours about patient safety are likely to be reflected in the
organisation’s working practices. For example, how patient safety incidents are investigated,
staff education, and training in risk management. The tool will be used to:
•
•
•
•
•
Facilitate reflection on patient safety culture
Stimulate discussion about the strengths and weaknesses of the patient safety culture
Reveal any differences in perception between staff groups
Help understand how a more mature safety culture might look
Help evaluate any specific intervention needed to change the patient safety culture
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Quality Improvement Model
To achieve our ambition we need an effective plan to engage with staff in all of our care
settings. The following diagram summarises the areas of work we will prioritise over the next
four years. Our intention is to identify variation in practice, apply service improvement
methodology and improve efficiency and flow.
Clinical Engagement
Effective teams
Organisational Structure
Governance Framework
Stakeholder Engagement
Leadership & Culture
Safety Culture
Safe Staffing
Open & Honest Care
Sign up to Safety
Staff Engagement
Quality Improvement
Projects
Harm Free Care
Improve
Outcomes
Listen and
Respond
Integrated Care
Outpatients Improvement
Patient Access & 7 day
working
Patient Flow & Discharge
Ward Environment
Advancing Quality
Harm Free Care
Integrated Teams
Productive Community
Improvement
Capability &
Measurement
Transformation
Methodology
Data Analysis
Listening in Action
Senior Leaders
Development Programme
Community Dataset
Patient Surveys / FFT
Staff Surveys /FFT
Clinical Audit Programme
Person Centred
User Engagement
Patient Communication
Dementia Care Training
Shared Decision Making
What Matters Most
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Our quality priorities for 2015 - 2016
Our priorities for 2015-2016 are consistent with our commitment to meet the requirements of
the NHS Outcomes Framework, which contains indicators selected to provide a balanced
coverage of NHS activity.
Harm-free care
Our trust has one of the most rapidly-ageing populations in England. Our patients are
increasingly frail and elderly, often with multiple long-term conditions that require regular
support and monitoring. Elderly patients are most vulnerable when they are unwell and
careful risk assessment is needed to ensure care plans are put in place to reduce risk of
avoidable harm.
The trust has committed to the national ‘Sign Up to Safety’ campaign. This initiative aims
to support the NHS in reducing avoidable harm by 50% within five years.
We will use the Summary Hospital-level Mortality Indicator (SHMIs), Risk Adjusted Mortality
Indicators (RAMI) and crude mortality data to help us better understand any trends
associated with patient deaths.
Medication errors
We will focus on ‘near misses’, omitted doses and low-harm incidents to further improve our
approach to effective medicines management.
What will the outcome be?
Year-on-year improvement in relation to medicines management with a 50% reduction, over
three years in omitted doses with no reason recorded.
Deteriorating patient
We will continue to roll out electronic systems (VitalPAC) to support the effective
monitoring and management of the unwell patient and to ensure timely escalation of the
deteriorating patient.
What will the outcome be?
All patients receive timely and responsive care in line with agreed care plan with appropriate
escalation and intervention as required.
Infection prevention and control
We will continue to have a zero-tolerance approach to MRSA Bacteraemia. We will work
towards an agreed improvement trajectory and year-on-year reduction in avoidable
Clostridium Difficile.
What will the outcome be?
The achievement of agreed performance standards.
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Safe staffing
We will improve our understanding of safe staffing and patient dependency ratios across
hospital and community services, strengthening service resilience over seven days, using
recognised and evidence-based tools to comply with NICE guidance on safe staffing.
What will the outcome be?
Clinical staffing levels in our community and hospital services will be benchmarked and
aligned to agreed ratios. These will be reviewed six-monthly using recognised dependency
assessment tools where these are available, supported by professional judgement.
Measured by?
Compliance with agreed levels for safe staffing will be monitored monthly with bi-annual
reports to Trust Board.
We will assess the organisational ‘safety culture’ on an annual basis using a nationallyrecognised tool, ensuring the trust demonstrates year-on-year improvement against the nine
domains of safety culture including overall commitment to quality, with priority given to
patient safety, organisational learning, education and team working in relation to safety
issues.
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Improving outcomes
We are a learning organisation that is committed to continuous improvement and our aim
is to provide the best possible evidence-based care. In some areas quality outcomes are
well-developed and understood and national and local indicators are in place. We will
continue to benchmark and monitor local performance to ensure we maintain quality
outcomes.
Our aim is to use the community datasets we have developed through the roll-out of
community nursing software system EMIS Web to agree and implement an effective
range of key performance indicators across community services which will enable a
consistent focus on quality outcomes across the organisation. These will be benchmarked
to ensure continued learning from best practice.
What will we do?
Quality data set community services - We will continue to work with our commissioners
and local GPs to develop and agree a range of quality outcomes for community services and
strengthen processes of data collection and clinical audit. We are already collecting activity
data for community services but an improved focus is required to assess the clinical
effectiveness, benefit to patients and any impact on other services. We will use information
intelligently to support improved clinical outcomes, enabling staff to have real-time access to
the care record in all settings.
Advancing quality - We will further develop the roll-out of advancing quality care bundles
that ensure a consistent approach to patient care management.
Access to service and seven-day working - We will strengthen the supporting
infrastructure for improved weekend working for example through enhanced ward clerk
cover, PALS outreach, pharmacy access and therapies.
Intelligent Information - We will continue to encourage staff to report incidents and use
data to understand how we can improve and share relevant learning across the organisation.
This will be supported by improved technology and the development of effective
performance reports that support the flow of key performance information from frontline
services to the Trust Board.
Clinical Audit - We will agree a programme of clinical audit to support the continued
improvement of quality outcomes, sharing learning and best practice across the
organisation.
NICE Quality Standards - We will further develop evidence-based practice, ensuring we
assess and appropriately implement NICE quality standards. This is important to ensure
consistency and reliability of care delivery and benefit to patients. We will link with
professional bodies regarding the development of safe staffing levels and monitoring of
planned fill rates.
Leadership - We will ensure our clinical staff are effective through a programme of appraisal
and revalidation, enabling them to feel empowered to deliver the highest quality care.
Ongoing development of core/specialist competency frameworks across all services for all
grades of staff. We will lead the development of new models of care, benchmarking local
service delivery against Royal College Standards and best practice.
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Listening and Responding
We are committed to further improving patient and staff experience by listening to
feedback and responding to concerns. We will shift the focus of our relationships with
patients from ‘what’s the matter?’ to ‘what matters most to you?’
What will we do?
Supporting vulnerable people
We will support the needs of individuals that require reasonable adjustments including
patients with learning disability, dementia and autism, further developing self-care models.
Engaging patients, carers and service users
We will ask patients and their carers to tell us about what matters to them. We will engage
service users in our services, building on our experience of involving patient representatives
on recruitment panels and service development groups. We will focus on shared decision
making with patients families and carers, involving staff in recognising the benefits of this.
Ward environment
We will improve the inpatient environment with a specific focus on reducing noise at
night, enabling television, radio and internet access and increased single-room
accommodation.
Timely discharge
We will improve our management processes to ensure there are no delays as a result of a
wait for take-home medications or discharge information.
Cancelled outpatient appointments
We will strengthen our clinic booking processes to reduce the number of cancellations. Each
specialty will have a trajectory of improvement.
End-of-life care
We will continue to encourage and support patients in identifying and achieving their
preferred place of care at end-of-life.
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Staff engagement and training
We will recruit staff who share our values, who are caring and compassionate.
We will continue to use ‘Listening into Action’ (LiA) methodology as a vehicle for improved
staff engagement within the organisation. This takes a conversational approach to
engaging staff at all levels for positive and effective change, supporting delivery of the
Quality Strategy by involving staff in co-designing quality improvement schemes.
There will be a focus on the harder-to-reach groups, particularly those working in
disparate community services.
We will also focus on engaging medical staff in leading quality initiatives and in further
strengthening the relationship between clinical staff and managers with a shared focus on
improving patient and staff experience
What will the outcome be?
•
•
•
•
•
•
•
the trust aims to be in the top 20% of trusts for key indicators of patient and staff
satisfaction.
year-on-year improvement in patient survey responses relating to noise at night,
discharge delays and hospital food.
year-on-year improvement in outpatient survey responses in relation to waiting times
for appointments and waiting times in the clinic.
year-on-year improvement in staff survey responses in relation to staff
recommendation of the trust as a place to work or receive treatment.
implement measurement strategy in community and deliver year-on-year
improvement.
more ‘better than expected’ responses on the outpatient survey.
positive responses to survey question: Do you feel your appointment today was
worth the time? (biannual survey).
How will we measure this and know we are improving?
We will monitor a range of relevant indicators including:
•
•
•
•
•
•
Friends and Family Test – patients and staff
patient experience surveys
complaints and PALS contacts
commissioning for Quality and Improvement Targets (CQUIN)
annual NHS Staff Survey and appraisal/professional revalidation process
staff will understand and be able to articulate the four principles of person-centred
care
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Integrated care
What is integrated care?
Many people who have complex care needs receive health and social care services from
multiple providers and in different care settings, without appropriate co-ordination or
holistic perspective. If services aren’t well coordinated and based around an individual’s
needs, it can lead to:
• confusion
• repetition
• delay
• duplication and gaps in service delivery
• people getting lost in the system
What will we do?
Place of care - we will develop effective partnerships and new ways of working within an
integrated care system to ensure patients receive care in the most appropriate setting for
their needs.
This includes the development of effective multi-disciplinary team working focussed around
the needs of patients, with the ability to respond to changes in care need in a flexible and
timely way that prevents avoidable hospital admission.
Community-based teams such as district nurses, community allied health professionals and
intermediate care teams provide high-quality and compassionate care within patients’ homes
or close by in community settings. We will ensure that out-of-hospital care and in-hospital
care are of an equally high quality and the transfer of care between services must not
appear disjointed for the patient.
Capability for integration
We will work with staff in both hospital and community settings to gain insight into their
ambitions for improved co-ordination of care and personalised delivery.
We will support community staff in developing their knowledge and skills and provide
practical support and resources from the service redesign team to enable transformation.
We aim to further strengthen and improve collective focus in the following areas:
•
•
•
•
•
•
•
•
•
integrated community teams
referral management processes
documentation
productive community improvement principles
mobile working
telemedicine
delayed transfers of care
paediatric community services
information sharing
What outcomes are we working towards?
We know that we can improve the way we work between hospital and community services
and with our partners.
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We have considered what will be different if we get it right and are aligning to the ambitions
of our commissioners. The following statements are examples of how we will evaluate our
success, placing the patient at the centre of our efforts.
How will we measure this and know we are improving?
•
•
•
•
•
•
patient satisfaction surveys in community settings
staff survey responses to question relating to staff feeling involved in innovating and
improving services for patients
successful roll-out of integrated health and social care community teams
involvement in national benchmarking and accreditation schemes e.g. IQIPS scheme
(Improving Quality in Physiological Services) for Audiology
development of EMIS to report clinical outcomes which are reported through the
service line scorecard
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Statements of assurance
A proportion of the income received at East Cheshire NHS Trust in 2014/15 was conditional
on achieving quality improvements and innovation goals agreed between the trust and its
commissioners. The goals agreed can be found at www.institute.nhs.uk or through the trust
website at www.eastcheshire.nhs.uk. East Cheshire NHS Trust has reviewed all of the data
on the quality of care in 2014/15 and the reports, achievements and improvements planned
can be seen throughout this report.
East Cheshire NHS Trust is required to register with the Care Quality Commission (CQC).
This report can be found at www.cqc.org and during 2014/15 successfully maintained
registration with no conditions.
A number of third party organisations have also had the opportunity to comment on the
trust’s Quality Account this year. The reports of NHS Eastern Cheshire, NHS South Cheshire
and NHS Vale Royal clinical commissioning groups and Healthwatch can all be found on the
following pages.
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East Cheshire Trust (ECT) Quality Account 2014/2015 commentary on behalf of
Eastern Cheshire Clinical Commissioning Group (ECCCG)
NHS Eastern Cheshire Clinical Commissioning Group (ECCCG) welcomes the opportunity
to comment upon the East Cheshire Trust (ECT) Quality Account for 2014/2015. ECCCG
have reviewed the content and believe this is an accurate and comprehensive account and
reflects the trust’s position with the quality of services provided during 2014/15.
ECCCG is the commissioner of the majority of services that East Cheshire NHS Trust
provides and this includes community services as well as acute services. The trust is also a
key stakeholder within the transformation of care in Eastern Cheshire; The Caring Together
Programme.
The trust’s Quality Account complies with the prescribed statutory and mandatory obligations
that it is required to adhere to. We have made this assessment from both our review of the
document, and from our on-going assessment of services through the year. On a monthly
basis we are provided with performance reports that inform us as to the quality of service
provision.
The trust has faced particular challenges this year which include sustained pressure on
services. Delivery of the A&E 4 hour treatment standard, as well as the 18 Week Referral to
Treatment standard, have been a challenge. The trust took the opportunity to help treat
those patients waiting longest for elective surgery through the national waiting list ‘amnesty’,
which was approved by the CCG, NHSE and the Trust Development Agency. The continued
success of this work has been challenged by the extraordinary winter pressures experienced
this year. For a prolonged period in Quarter 4 the trust faced challenges with achieving
these standards but has been pro-active in addressing the issues through improvement work
centred on flow and capacity with a particular focus on reducing Delayed Transfers of Care
which would release bed capacity.
The trust has continued to improve in other areas of quality through initiatives such as Sign
up to Safety and through its Open and Honest Care Programmes, which have seen real
developments in the provision of Harm Free Care. The trust has embraced the safety
agenda and as an organisation they have set their objectives to delivering safety by reducing
harm factors such as pressure sores and falls related harm.
We welcome and recognise the priority areas that the trust has set out in its work to develop
quality outcomes through its Quality Strategy and we look forward to working collaboratively
with them to further develop quality and safety for the services it delivers to the population of
Eastern Cheshire.
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East Cheshire Trust (ECT) Quality Account 2014/15 commentary on behalf of NHS
South Cheshire CCG and NHS Vale Royal CCG
NHS South Cheshire Clinical Commissioning Group (CCG) and NHS Vale Royal Clinical
Commissioning Group (CCG) welcome the opportunity to comment on East Cheshire NHS
Trust (ECT) Quality Account 2014/15.
We have reviewed the content of the Quality Account and confirm that this complies with the
mandatory elements required. However, it is important to point out that the services
commissioned by NHS South Cheshire CCG and NHS Vale Royal CCG from ECT are
predominantly community services, which will be the primary focus of our comments.
It was pleasing to see the introduction of the specialist community stroke rehabilitation
services for South Cheshire and Vale Royal as one of the highlights in the ‘Year at a Glance’
section. This was further supported by a positive patient story that illustrated the pathway
that was available and the benefits of having the intervention from the specialist community
stroke rehabilitation team including earlier discharge from hospital and from the rehabilitation
service. However, there was little in the document that related directly to other community
services that we commission and it would have been appreciated to see these reflected
along with any plans for improvements.
While the content of the patient stories reflects many of the 6C’s from Compassion in
Practice it would have been, in our opinion, useful to have a section dedicated to this
subject. This could have included the basics of the 6C’s, how it is being implemented in the
community settings and what the plans are to ensure that Compassion in Practice is
embedded within the teams and across the organisation.
The detail about the trust committing to the ‘sign up to safety’ campaign was minimal with
the emphasis being on the priority areas where avoidable harm could be reduced. While
those aims are to be commended it could have been useful to summarise what the pledges
and action plans are for the campaign and how this is going to be communicated to frontline
teams and other areas in the organisation.
We recognise and value the plan for the trust to continue working with NHS South Cheshire
Clinical Commissioning Group and NHS Vale Royal Clinical Commissioning Group to
develop and agree quality outcomes. We look forward to working together to identify quality
outcomes for community services and strengthen the process for data collection and clinical
audit particularly looking at the benefit to patients and impacts that occur.
No learning was highlighted from Adult Safeguarding or the large scale work that has been
done with ECT regarding the commissioning standards. Instead safeguarding is only
mentioned in relation to the annual maternity safeguarding audit. This feels like a missed
opportunity and could have provided a scale of measurement and audit that could be
threaded through all the service developments.
In 2015/16 we look forward to continuing working together in an open and collaborative
manner in order to both develop and improve the quality of community services for our local
population.
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Healthwatch Cheshire East response to East Cheshire NHS Trust Quality Account
2014-2015
Healthwatch Cheshire East welcomes the opportunity to comment on the East Cheshire
NHS Trust (ECT) Quality Account 2014/2015.
Healthwatch Cheshire East acts as the champion for the voice of the consumer and as such
our comments and views on this report focus on how ECT have involved and listened to their
consumers views (patients and their families).
Healthwatch Cheshire East has received many positive stories from the community praising
the treatment and care received from the staff and volunteers at the trust. We recognise that
the trust and the services it delivers are valued by the local community.
We welcomed the recognition and importance that the trust has placed on patient
involvement and utilising patient stories to improve service delivery. Within the Quality
Priority for 2015/2016 - Listening and Responding, we would have liked to have seen greater
reference to ensuring that the trust specifically engages, listens and responds to patient
groups that are seldom heard.
We have also received comments raising similar concerns to those the trust identified
through the FFT with consumers reporting that there was a lack of staff on wards or very
busy staff. We have been told that the impact of this on patients and their families makes
them feel worried, concerned and distressed. We would therefore have liked to see how the
trust was addressing this clearly reflected in the quality priorities for 2014/2015. We did
welcome the target to increase the number of volunteers in the trust as these roles would
add value to the care provided to patients.
We recognise that there have been significant challenges for the trust during 2014/2015 and
value the relationship that Healthwatch Cheshire East and the trust have. We look forward
to working with the trust during 2015-2016 to enable our community to have a powerful voice
helping to shape and improve these services for the future.
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If you would like more information regarding this document or if you require another
language or format of this document (including easy read and audio) please contact
us using our address details below:
By post
East Cheshire NHS Trust
Macclesfield District General Hospital
Victoria Road
Macclesfield
Cheshire
SK10 3BL
By telephone
01625 421000 Main Switchboard
01625 661184 Communications department
Via our website
www.eastcheshire.nhs.uk
By fax
01625 661000
Follow us on twitter@eastcheshirenhs
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